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The standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the cri teria for privileges in that area of practice 50 mg cozaar visa diabetes and definition. Provisional privileges in primary care 25 mg cozaar visa diabetes diet soda, obstetric care order cozaar 25 mg visa blood sugar insulin, and cesarean delivery should be granted regardless of specialty as long as training criteria and experience are documented order cozaar 50mg visa blood glucose experiments. All physicians should be subject to a proctorship period to allow demonstration of ability and current competence. Privileges recommended by the department of family practice shall be the responsibility of the department of family practice. Similarly, privileges recommended by the department of obstetrics and gynecology shall be the responsibility of the department of obstetrics and gynecology. When privileges are recommended jointly by the departments of family practice and obstetrics and gynecology, they shall be the joint respon sibility of the two departments. Requests for New Privileges New Equipment and Technology New equipment or technology usually improves health care, provided that prac titioners and other hospital staff understand the proper indications for usage. Problems can arise when staff perform duties or use equipment for which they are not trained. It is imperative that all staff be properly trained in the use of the advanced technology or new equipment. That is, each physician requesting addi tional privileges for new equipment or technology should be evaluated by answering the following three questions: 1. Does the hospital have a mechanism in place to ensure that necessary support for the new equipment or technology is available Has the physician been adequately trained, including hands-on experi ence, to use the new equipment or to perform the new technology Has the physician adequately demonstrated an ability to use the new equipment or perform the new technology This may require that the physician undergo a period of proctoring or supervision, or both. If no one on staff can serve as a proctor, the hospital may either require reciprocal proctoring at another hospital or grant temporary privileges to someone from another hospital to supervise the applicant. Specifically, if the new privileges were not included in residency training, the applicant must do the following: � Complete a preceptorship with a physician already credentialed to per form the procedures of that skill level; the preceptorship should require the applicant to perform the designated surgery with the preceptor act ing as first assistant. If there is no experienced surgeon on the hospital staff who is able to serve as a preceptor for advanced or new surgical procedures, a supervised preceptorship must be arranged. This may be done by scheduling a number of cases from phy sicians requiring credentialing and inviting a credentialed surgeon from another institution to serve as a surgical consultant. After a Period of Inactivity the American Medical Association defines physician reentry as �a return to clinical practice in the discipline in which one has been trained and certified Appendix D 487 following an extended period of inactivity� (2. This section will not address inactivity that results from discipline or impairment. There are several reasons why a physician might take a leave of absence from clinical practice, such as family leave (maternity and paternity leave and child care); personal health reasons; career dissatisfaction; alternate careers, such as administration; military service; or humanitarian leave. Traditionally, women were more likely to experience career interruptions; however, recent research shows that younger cohorts of male physicians also take on multiple roles and express intentions to adjust their careers accordingly (2. When physicians request reentry after a period of inactivity, a general guide line for evaluation would be to consider the physician as any other new applicant for privileges. Demonstration that a minimum number of hours of continuing medi cal education has been earned during the period of inactivity. It is also important to meet any board certification requirements during the absence. In accordance with the medical staff bylaws, supervision by a proctor appointed by the department chair for a minimum number and defined breadth of cases during the provisional period, evaluating and docu menting proficiency. A time-sensitive, focused review of cases as required by the departmen tal quality improvement committee may be completed as appropriate. The area of skills assessment may prove challenging if the previous guide lines, number 2 and number 3, are not felt to be adequate. Residency Training Programs Benefits: More locations are available, providing structured didactic programs, and implementing competency assessment. Participating in these programs can provide a source of manpower to help com pensate for restricted residency work hours. Drawbacks: Many hospitals with residency programs have only a lim ited number of cases available for training. Reentry programs must not negatively affect the residency training program (ie, if someone is being brought into a reentry program in an institution that has a residency program, the Residency Review Committee must be noti fied with an explanation as to how it will not negatively affect the residents. Simulation Centers Benefits: these centers can help supplement hands-on clinical experi ence and may be more geographically accessible. Drawbacks: Currently there is a limited number of functioning simu lation centers, though this number should continue to expand. Physician Reentry Program Benefits: Well-designed physician reentry program systems should be consistent with the current continuum of medical education and meet the needs of the reentering physician. Drawbacks: Only a few physician reentry program systems are offered nationally; thus, cost and location are considerable obstacles in utiliz ing these programs. An underlying assumption is that physicians do not necessarily lose com petence in all areas of practice with time. Competencies, such as patient com munication and professionalism, may not decline. Therefore, a reentry program should target those areas where physicians are more likely to have lost relevant skills or knowledge, or where skills and knowledge need to be updated (3.

Sports and Exercise Medicine 145 complete rupture) cheap 25mg cozaar otc diabetes symptoms uk, the muscle or ligament affected (e 50 mg cozaar with visa managing diabetes holistically. The impact of any injury is of course further complicated by the func tional aspirations of the individual and their age buy cozaar 25mg visa diabetes symptoms weight, which will affect the site of injury and the potential for healing generic 50mg cozaar otc inborn metabolic disease 5th edition. Ankle sprain�Inversion injuries to the lateral ligament complex of the ankle are one of the most common causes of long-term disabil ity after injury. Injuries initially occur in plantar exion and slight inversion, such as at push off (Figure 22. After the acute injury, the degree of soft-tissue damage can be estimated by the extent of the swelling, and the likelihood of bone injury by clinical features (Box 22. Ankle sprain can result in additional damage that may cause either ongoing instability or chronic pain (Box 22. Clinical assessment includes assessment of balance and proprio ception, mechanical stability, sites and degree of tenderness, and neurovascular status. Management of the acute injury should focus on early mobilization, range of motion and strengthening exercises Figure 22. Although most stress injuries are fatigue-related, the possi Duration bility of insufciency fractures, particularly in lightweight athletes, Frequency must always be considered. Most stress fractures will respond to Intensity relative rest, support and correction of the underlying cause (train � Resistance training � Flexibility training ing, biomechanics, equipment errors. However, certain stress frac Address issues such as adverse biomechanics from osteoarthritis tures are associated with an increased risk of poor healing/ before commencing; counselling, supervision and progression of completion, including the superior surface of the femoral neck, programme anterior tibial cortex and navicular. These are areas that are under tension (rather than compression) and/or have poor vascular supply. They are managed either by non-weight-bearing and close monitoring or early surgical intervention (Figure 22. Common sports injuries�the chronic/overuse injury Exercise prescription Whereas acute injuries are more common while working in a com petitive sporting environment, the injury that presents most com the benets of exercise in the prevention and management of monly to a sports medicine clinic is the overuse injury. Many patients with rheumatological injuries are dened by the inability of a normal structure to cope diseases should be given an exercise prescription, as many are at with an excessive load, as opposed to an insufciency injury, in increased risk of medical complications such as osteoporosis and which a pathologically weak structure is unable to cope with a cardiovascular events. This may need to be modied for those with diseases such the most common sites being the tibia, metatarsals and lumbar as rheumatoid arthritis, but provides a target. Supervision of patients may be ing to the wider impact of activity-related musculoskeletal injury. Compliance is enhanced by education and counselling, It is therefore important that rheumatologists are condent in the careful prescription in choice of activities, written information assessment and rehabilitation of the exercising individual. Patients present with a consti � Urinalysis is a key investigation, as renal involvement is a major determinant of outcome. Systemic � Cyclophosphamide therapy should be used only for induction of � Malaise remission; maintenance therapy should be with azathioprine or � Fever methotrexate in combination with glucocorticoids. Systemic necrotizing vasculitis can be rapidly Gastrointestinal life-threatening, so early accurate diagnosis and treatment is vital. The severity of � Cough vasculitis is related to the size and site of the vessels affected. Angiography shows typical arteritis, often with formation of granulomas (Figure 23. Microscopic polyangiitis Kawasaki disease (mucocutaneous lymph node this is characterized by a vasculitis that commonly affects the kidneys. Lung involvement usually presents with haemoptysis syndrome) caused by pulmonary capillaritis and haemorrhage (pulmonary An acute vasculitis that primarily affects infants and young chil renal syndrome. It presents with fever, rash, lymphadenopathy and palmo Biopsy of the kidney shows a focal segmental necrotizing plantar erythema. Coronary arteries become affected in up to glomerulonephritis with few immune deposits (sometimes called one-quarter of untreated patients; this can lead to myocardial pauci immune vasculitis. Medium and small-vessel vasculitis Churg�Strauss syndrome this syndrome is characterized by atopy (especially late-onset this group includes the major necrotizing vasculitides: micro asthma), pulmonary involvement (75% of patients have radio scopic polyangiitis, Wegener�s granulomatosis and Churg�Strauss graphic evidence of inltration) and eosinophilia in the tissues and syndrome, with involvement of both medium and small arteries. Such features can develop several these may occur at any age, with the peak incidence at 60�70years years before the onset of systemic vasculitis. The annual incidence is is a particular feature of Churg�Strauss syndrome and determines about 20 cases per million people. Small-vessel vasculitis Wegener�s granulomatosis Small-vessel vasculitis (leucocytoclastic or hypersensitivity) is this is characterized by a granulomatous vasculitis of the upper usually conned to the skin, but it may be part of a systemic illness. Biopsy shows a cellular inltrate of small vessels often and throat (such as epistaxis, crusting and deafness) are particularly with leucocytoclasis (fragmented polymorphonuclear cells and associated with this condition, and they should be sought in all nuclear dust. Small-vessel vasculitis has a number of causes, of patients with suspected vasculitis. The condition presents with rash (including purpura digital ischaemia and ulcers) (Figure 23. A strong link exists between infection with hepatitis C virus and essential mixed cryoglobulinaemia: 80�90% of such patients are positive for anti hepatitis C virus antibodies. Behcet�s syndrome Behcet�s syndrome is a systemic vasculitis of unknown aetiology, characterized by oro-genital ulceration. Ocular involvement occurs early in the disease course and affects 50% of patients. The pathergy phenomenon is characteristic and is a non-specic hyperreactivity in response to minor trauma. Investigation Investigation aims to establish and conrm the diagnosis, the Figure 23. Henoch�Schonlein purpura Urine analysis this is a form of small-vessel vasculitis that occurs mainly in chil this is the most important investigation, because the severity of dren and young adults. Patients present with rash, arthritis, abdom renal involvement is one of the key determinants of prognosis. Deposits Detection of proteinuria or haematuria in a patient with systemic of immunoglobulin A can be detected histologically in the skin and illness needs immediate further investigation, and the patient is a renal mesangium.

In such a knee cozaar 50 mg with amex diabetes type 1 frequent urination, the incidence of concomitant injury laxity when the knee is flexed suggests more isolated to one or both cruciate ligaments is extremely high discount cozaar 50mg online diabetic uropathy. Flexing the knee relaxes the pos divided into three grades according to the physical find teromedial capsule and concentrates the force on the ings discount cozaar 25 mg on-line blood sugar quiz. This means that the medial joint separates separation of the femur and the tibia generic 50mg cozaar with mastercard diabetic desserts, this time on the lat more than in the other knee when a valgus stress is eral side of the knee, in response to the varus stress. In the applied, but a firm resistance is eventually felt when the normal knee, virtually no separation of the lateral tibia injured ligament pulls taut. In When the lateral ligamentous structures are torn, the other words, the examiner feels no resistance no matter femur and the tibia are felt to separate abnormally when how far the medial joint surfaces are separated. Although the stress is applied and to clunk back together when the this is the most widely accepted system of classification, it stress is relaxed. This separation is probably about 3 mm to not there is increased valgus laxity in full extension, 5 mm in the average normal knee. The varus stress test is the counter the ability to translate the tibia anteriorly an abnormal part of the valgus stress test for detecting injury to the amount in relation to the femur. Again, the patient lies supine and fully increased anterior laxity is a sign of injury to the anterior relaxed. As in the other ligaments can increase the magnitude of the abnor valgus stress test, the knee is first tested in full extension mal anterior translation. In the anterior drawer test, the the knee to 90� if the knee is acutely injured and painful. If the patient is properly relaxed, the lower limb surpassed the anterior drawer test as a basic screening should feel as if it would fall over to the side if the exam examination for abnormal anterior knee laxity. The examiner then pulls forward with was first described by Torg and attributed to his mentor, both hands (Fig. The Lachman test is similar in concept to the anterior translation of the tibia with respect to the femur 0 anterior drawer test but is performed with the knee in 20 and the quality of the endpoint. In most patients, the tibia can be felt to move for Again, the patient lies supine on the examination ward at least a few millimeters and then stop suddenly table (Fig. As in the other stability tests, com table near the knee and grasps the lower leg with one parison to the other side is important. The thumb of this Although the anterior drawer test is the most well upper hand presses against the femur through the quadri known test for abnormal anterior knee laxity, it has some ceps tendon while the other fingers wrap around the pos problems and limitations. As in the anterior drawer some patients with greater than average anterior knee lax test, the amount of anterior excursion and the quality of ity may demonstrate a mild physiologic pivot shift in the the endpoint are assessed. Many patients whose knees One of the differences that makes the Lachman test hyperextend can be expected to demonstrate this physio easier to assess than the anterior drawer test is that in logic pivot shift. Either no shift, although sectioning the lateral ligament complex translation at all or 1 mm to 2 mm of translation with a usually increases the magnitude of the pivot shift. The classic pivot shift test was tear, the translation is increased and the endpoint indef described by Galway and Mcintosh. Often, this increased translation can be visibly supine and relaxed, the examiner lifts the lower limb off appreciated by focusing on the forward movement of the the table by the foot and internally rotates it (Fig. In subtly abnormal cases, the examiner may not test is performed with internal rotation of the lower limb, be sure that increased excursion is present, but he or she some researchers recommend a neutral or even externally may sense a soft end point that differs from the unin rotated position. This may be a straight position or hyperextension, cases, increased anterior laxity is present but a firm end depending on what is normal for that particular patient. This endpoint is usually easier to If the knee does not fall into full extension, whether due appreciate after the swelling and stiffness of the acute to pain, swelling, or a displaced meniscus tear, the pivot injury have subsided. In most the femur to fall posteriorly when the limb is held in this patients with a physiologic pivot shift, such a pivot glide manner, resulting in an anterior subluxation of the tibia is present. The examiner then places the subluxes so far anteriorly when the knee is extended that palm of the other hand on the lateral aspect of the proxi a spontaneous reduction does not occur as the knee mal leg, just below the knee, and gently applies a force flexes. In these cases, the knee appears to be stuck that results in valgus stress as well as flexes the knee (see between 20� and 30� of flexion and docs not flex past the Fig. Somewhere between 20� and 30�, the anteri sticking point until the examiner manually pushes the orly subluxed tibia spontaneously reduces into its normal tibia posteriorly into a reduced position. Several variants of the pivot shift test have been jump is at the tubercle of Gerdy. In the jerk test, described by Hughston, the uals, the knee bends smoothly with no such shift. The flexion-rotation pivot shift or pivot glide in which the tibia can be seen to drawer test is a gentler version of the pivot shift test that move smoothly into a reduced position as the knee flexes, has become quite popular. The internal rotation, valgus, patient must identify the subluxation maneuver as his or and flexion forces are applied indirectly at the ankle (Fig. A good the next group of tests are those for abnormal posterior method is to begin with the flexion-rotation drawer test laxity of the knee. The Losse test is another technique for tures further increases the magnitude of the abnormal demonstrating the pivot shift phenomenon. When such a sublux anteriorly as the knee approaches full extension dropback phenomenon occurs, the tibial tubercle appears Figure 6-52. The results of the posterior drawer and dropback tests are usually graded by the rela tionship of the proximal tibia to the distal end of the femoral condyles. Normally, the anterior cortex of the proximal tibia sits about 10 mm anterior to the distal end of the femoral condyles when the knee is flexed about 90�. Every 5 mm of posterior dropback or posterior drawer is considered a grade of abnormal laxity. Thus, in a grade 1 posterior drawer, the normal 10 mm of prominence of the anterior tibia with respect to the femoral condyles is Figure 6-53. In a grade 2 posterior drawer or drop concavity of left knee profile (in foreground. In the grade 3 or grade 4 posterior drawer or less prominent than usual, and the patella appears more dropback, the anterior tibial cortex is respectively dis prominent than usual.

This deformity is manifested by a large visible bump proven cozaar 25 mg metabolic bone disease icd 10, to acute fractures or malunions of prior fractures are especially over the supralatcral corner of the calcaneal usually quite obvious cheap cozaar 50 mg without a prescription type 1 diabetes xanax. Thickened skin and subcutaneous stress fracture that occurs at the midpoint of the anterior bursal enlargement may further increase the prominence tibial crest is often visible as a small lump arising along of this deformity effective 25 mg cozaar blood sugar 310. Lateral to the tibial crest lie the anterior com least exacerbated buy cozaar 50 mg on line metabolic disease ketonuria, by shoe pressure over the calcaneal partment muscles, the tibialis anterior and the toe exten tuberosity, this deformity is often popularly described as a sors. More proximally, the Achilles tendon can be seen tures already seen and to visualize some new ones (Fig. From this viewpoint, the base of the fifth its insertion on the calcaneal tuberosity. This subcuta metatarsal and the lateral malleolus are seen bulging neous tendon should be visible in virtually all individuals. Distal to the lateral malleolus, a soft Achilles tendinitis (tendinosis) and rupture usually occur fleshy mound is seen in most individuals. A, medial malleolus; B, lateral malleolus; C, tibialis anterior tendon; D, extensor hallucis longus; E, extensor digitorum longus; F, anterior inferior tibiofibular ligament; G, peroneus tertius. Bony contours that are visible from the medial per spective include the head of the first metatarsal, the cal Calf. More proximally, the Achilles tendon fans out into a caneal tuberosity, and the medial malleolus. This latter flat aponeurosis over the posterior aspect of the soleus landmark usually appears as a pointed prominence. Still higher on the leg, the two Distal and anterior to the medial malleolus, the examiner distinct heads of the gastrocnemius insert into this com often can see the much smaller prominence created by the mon aponeurosis. When an accessory navicular or eral heads of the gastrocnemius are visible in many cornuate navicular is present, the prominence of the individuals, especially if the patient is asked to perform a navicular tuberosity may be increased until it rivals that toe raise (Fig. Patients with such anom Because the normal bulk of the calf muscles can vary alies often describe themselves as having two ankle bones. Of all these structures, only the tib iner a direct view of the arch and the vicinity of the ialis posterior is normally visible, and resisted inversion major neurovascular bundle (Fig. When this resistance is applied, the tibialis posterior tendon is most easily seen between head of the first metatarsal and the calcaneal tuberosity the posterior edge of the lateral malleolus and its inser should arch away from the floor. A, subcutaneous border of the tibia; B, anterior compartment muscles; C typical site of anterior crest stress fracture; D, site of tibialis anterior peritendinitis; E, site of possible superficial peroneal nerve compression. From this perspective, the anterior portion of the leg is defined by the straight margin of the subcutaneous border of the tibia, whereas the posterior margin is defined by the contours of the soleus and the medial head of the gastrocnemius. However, careful inspection of the skin of the plantar sur face allows the examiner to deduce information concern ing the function of the foot during weightbearing. Areas of thickened or callused skin should be noted because they reflect the weightbearing pattern of the foot and can thus help identify areas of excessive weightbearing. Such areas of thickened skin commonly occur along the lateral foot and underneath the metatarsal heads. Intractable plantar keratosis is the term usually applied to the frequently painful accumulations of callused skin that can form beneath the metatarsal heads (Fig. A, soleus; B, medial gastrocnemius; C, lateral gastrocnemius; D, usual site of gastrocnemius tear. In general, thickening of the stratum corneum of the skin is referred to as a hyperkeratosis or callus. When further cushions the tips of the toes, the metatarsal hyperkeratoses are distinct and isolated, they are usually heads, and the calcaneus. Helomas may be further the skin beneath the middle and proximal phalanges subdivided into heloma durum, or hard corn^ and of the toes and the plantar surface of the arch is normally heloma molle, or soft corn. In the molle is usually located deep in the web spaces between presence of more severe deformities, such as the rocker the toes, where it forms from pressure of an adjacent toe bottom foot, the weightbearing pattern may be even more against an osteophyte or prominence of one of the bizarre. In the normal foot, the skin involved in weightbear ing describes a specific pattern: the areas beneath the the skin should also be inspected for cutaneous dis distal phalanges of the toes, the metatarsal heads, a thin orders such as warts or rashes. Plantar warts are cuta strip along the lateral border of the foot, and an oval neous excrescences a few millimeters in diameter that can area beneath the plantar surface of the calcaneus. Not be the source of considerable pain if they form beneath only is the skin thickened in these areas but also the metatarsal head or the tuberosity of the calcaneus (see increased subcutaneous tissue in the form of fat pads Fig. A, medial longitudinal arch; B, head of the first metatarsal; C, calcaneal tuberosity; D, medial malleolus; E, navicular tuberosity; F, saphenous vein; G, posterior tibial tendon; H, flexor digitorum longus tendon; I, posterior tibial artery; J, typical site of stress fracture of the medial malleo lus; K, deltoid ligament. Splayfoot is a condition in which the metatarsals tend to spread broadly during wcightbearing, whereas the term metatarsus primus varus refers specifically to a first metatarsal that angles excessively toward the midline. The opposite deformity, hallux varus, almost never occurs spontaneously, but it may be found as an unwanted complication of surgery to correct hallux val gus. In hallux varus, the great toe deviates away from the rest of the toes toward the midline (see Fig. Normally, the second through fourth toes should be straight and the fifth toe should be slightly supinated and curved in toward the fourth. Hammer toe usually involves a single digit and con sists of hyperextension of the metatarsophalangeal and distal interphalangeal joints combined with hyperflexion Figure 7-22. Inverting the foot against resistance to demonstrate the of the proximal interphalangeal joint (Fig. At Inspection of the foot and the ankle for malalignment times, even the hallux may be clawed. Normally, the great toe should tip of the involved toe, often producing a callus (see point directly forward when the patient is standing with Fig. In this condition, a val A major factor in the production of all these deformi gus deformity occurs at the first metatarsophalangeal ties is thought to be the longterm use of ill-fitting footwear joint, which causes the great toe, the hallux, to deviate because they occur more commonly in shoe-wearing soci away from the midline (Fig. Another important factor great toe may be pronated or even overlap the second toe. Rheumatoid arthritis can produce an amazing term bunion specifically refers to the accumulation of bone and thickened soft tissue on the medial aspect of the first variety of abnormalities of toe alignment (Fig.

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However buy generic cozaar 25mg on-line diabetes type 1 diagnosis, in cases of arthritis resulting from previous dislocation and avascular necrosis cheap 50mg cozaar overnight delivery diabetes test online uk, the patient�s age may be in the range of 40 to 50 years 50 mg cozaar with mastercard diabetes pharmacology test questions. Patients� symptoms often include shoulder pain generic cozaar 50 mg without a prescription diabetes mellitus medical definition, functional limitations in motion, and radiographic deterioration of the gleno humeral joint. Primary glenohumeral degenerative joint disease presents with central wearing of the humeral head, known as the �Friar Tuck�pattern of central baldness. The glenoid surface wears out primarily on the posterior margin, predisposing the joint to posterior subluxation. A third type of prosthesis, called a reverse prosthesis, has been developed to place the ball component on the glenoid side and the socket on the humeral side (see gure. This design is advantageous for patients with a decient cuff because it places the deltoid in a better biomechanical position by medializing the center of rotation so more bers assist in elevation. The prosthesis can also be placed to lengthen the bers of the deltoid to take advantage of the length tension relationship, thereby improving function. A hemiarthroplasty is indicated when the humeral head is deteriorated or fractured but the glenoid surface is intact. Hemiarthroplasty is the surgery of choice if the patient has insufcient glenoid bone to support a glenoid component. When the physical demands are heavy after surgery, a hemiarthroplasty is indicated. Hemiarthroplasty is indicated when arthritis and rotator cuff deciencies coexist. A badly eroded glenoid cannot stabilize a glenoid component securely, and a nonfunctional rotator cuff produces unbalanced muscular forces on the glenoid, leading to loosening. Hemiarthoplasty can replace the entire humeral head or be a resurfacing prosthesis. This procedure is undertaken when both joint surfaces are damaged and both are reconstructable. Multiple studies showing consistent relief of pain and improved function support this statement. There are times, however, when the deteriorated bone of the glenoid cannot support the prosthesis or the deciency of the rotator cuff requires the use of hemiarthroplasty. Patients without erosion of the glenoid have been found to have improved function following a hemiarthroplasty. Patients suffering from osteoarthritis or osteonecrosis tend to have higher levels of function following surgery than patients with rheumatoid arthritis and cuff tear arthropathy. Yes, but it should be considered as a salvage procedure because a recent report determined that nearly 50% of patients who had undergone this procedure were unsatised with the outcome at 2 years. The advent of the modular components could lead one to believe that converting to a total shoulder replacement would be a good choice; however, recent evidence suggests that this is not the case. Most complications are due to mechanical loosening, instability, and implant failure. Tearing of the rotator cuff accounts for approximately 13% of postoperative complications. Superior humeral migration occurs at the same incidence; it often is associated with glenoid component loosening but is usually not as painful. Operative complications are slightly higher in patients with rheumatoid arthritis because of poor tissue quality. The many contributing factors include glenoid preparation, soft tissue balancing, wear debris, bone reabsorption, prosthetic design, component geometry, and biomaterials. One major concern is the eccentric load placed on the glenoid component by the humeral component, particularly if the humerus has migrated superiorly. The humerus can migrate superiorly because of rotator cuff tear, poor humeral xation, and soft tissue imbalance. During arm elevation the eccentric load of a proximal migrated humeral component can produce a �rocking horse� effect on the glenoid component that loosens the glenoid component. The secondary goal is to restore normal function, specically shoulder range of motion. Regaining upper extremity strength and ensuring stability of the components are additional postoperative goals. A smaller study of 53 operations, using similar criteria, reported that at 11-year follow-up 27% had failed. A recent publication by Orfaly has demonstrated that in the hands of outstanding surgeons both procedures can provide excellent improvement in function, decrease pain, and improve range of motion. Both groups� active elevation improved approximately 50 degrees, and external rotation improved 30 degrees. The patient should be counseled by the physician and therapist that activities that expose the patient to high-impact events are not recommended because of the potential trauma to the prosthesis. However, sports such as swimming, bowling, dancing, and bicycling can be resumed when appropriate healing has occurred. Limited-goal rehabilitation is meant for patients who have decient rotator cuff and deltoid musculature and signicant bony deciency that does not tolerate the typical rehabilitation program. Patients who have long-standing rheumatoid arthritis and rotator cuff arthropathy as well as some revision arthroplasties may fall into this category. The shoulder functions primarily at the side with elevation restricted at or below 100 degrees and external rotation of 20 degrees. Education about postoperative exercise regimens and typical postoperative symptoms alleviates the patient�s apprehension. Early passive motion should be initiated on day 1 or 2 after surgery to prevent intra-articular adhesions and soft tissue contractures.