Exercise PROGRESSION and rehabilitation considerations following rotator cuff repair

1. Alison Deichert PT, DPT September 17, 2011 Midwest Student Conclave Exercise PROGRESSION and rehabilitation considerations following rotator cuff repair

2. 0.7-2% of population per year seek medical attention for shoulder complaints (Roddey 2002) RTC tears become more common after 40 years of age (Boissonnault 2007) Partial thickness tears peak between ages 50-60 (Boissonnault 2007) Full thickness tears peak after age 60 (Boissonnault 2007) Five to forty percent of population over age 60 has evidence of full thickness rotator cuff tear (Boissonnault 2007) PREVALANCE OF ROTATOR CUFF INJURIES Percentage even higher for athletesPercentage even higher for athletes

3. Rotator cuff musculature

4. Dynamic stabilizer of rotator cuff in multiple positions (Reinold 2009) Balances force couples about the glenohumeral joint (Lo 2003) Helps to resist superior translation of humeral head, to center the humeral head in the glenoid Inman (1994) discussed coronal plane force couple between deltoid and posterior cuff (infraspinatus, teres minor, and subscapularis) Transverse plane force couple is subscapularis anteriorly balanced against infraspinatus and teres minor (Lo 2003) Rotator cuff FUNCTION If infraspinatus and teres minor torn then will not create large enough moment to balance posterior cuff and humeral head will translate superior and anteriorly. Goal with sx is to return normal force alignment Rotator cuff counteracts shearing force generated by deltoid-creates compression of HH in glenoidIf infraspinatus and teres minor torn then will not create large enough moment to balance posterior cuff and humeral head will translate superior and anteriorly. Goal with sx is to return normal force alignment Rotator cuff counteracts shearing force generated by deltoid-creates compression of HH in glenoid

5. Has greatest ROM of any joint in body (Wilk 1997) Articular surface of glenoid is pear shaped Glenoid is much smaller then humeral head During normal motion only 25-30% of the humeral head is actually in contact with glenoid (Wilk 1997) GLENOHUMERAL JOINT Inherently unstable-most commonly dislocated joint-sacrifices stability for mobility Surface area of humeral head is 3-4x that of glenoid Main function of the glenohumeral joint-to position the hand for function Golf ball on a teeInherently unstable-most commonly dislocated joint-sacrifices stability for mobility Surface area of humeral head is 3-4x that of glenoid Main function of the glenohumeral joint-to position the hand for function Golf ball on a tee

6. Glenohumeral joint

7. ROLE IN STABILITY: provide stable base of support for glenohumeral joint muscles to function from (Wilk 1997) Maintains a dynamic and consistent length tension relationship for shoulder girdle Correlation exists between weak scapular muscles and MDI (Wilk 1997) SCAPULOTHORACIC MUSCULATURE

8. EDUCATE YOUR PATIENT: Sling wear, wound management, healing times, safety PROTECT THE REPAIR IMPROVE DYNAMIC STABILIZATION DECREASE PAIN PROMOTE HEALING RESTORE PASSIVE MOTION IMPROVE MUSCULAR STRENGTH AND BALANCE (Ghodadra 2009 and Wilk 2009) REHABILITATION GOALS FOLLOWING ROTATOR CUFF REPAIR 12 weeks to obtain adequate pull out strength of the repair12 weeks to obtain adequate pull out strength of the repair

9. OPEN MINI-OPEN DELTOID SPLITTING TECHNIQUE ARTHROSCOPIC TYPES OF ROTATOR CUFF REPAIR

10. First rotator cuff repair was done in 1911 by Dr. Codman using open technique (Ghodadra 2009) 5 Fundamentals of Repair according to Neer in 1972 include: Meticulous repair of deltoid origin Subacromial decompression Surgical releases as necessary to mobilize tissue Secure fixation of tendon to tuberosity Closely supervised rehab with early PROM (Ghodadra 2009) OPEN ROTATOR CUFF REPAIR

11. 3-6 inch incision made over anterior superior aspect of the shoulder Deltoid taken off acromion and split for 3-5 centimeters Deltoid must be reattached following repair OPEN ROTATOR CUFF REPAIR PROCEDURES

12. PROS: Allows for easier visualization of tissue Good for repairing large or massive tears Complication rate of 10.5% (Mansat 1997) Demonstrates high rates of pain relief, functional improvement, improved ROM, and overall patient satisfaction in various studies CONS Increased postoperative pain Deltoid takedown Infection risk/hospitalization (Lindenfeld 2009) Slower rehab-longer period of protection and/or immobilization following deltoid takedown and repair (Ghodadra 2009) OPEN ROTATOR CUFF PROS/CONS

13. Levy developed in 1994 to avoid deltoid issues Uses arthroscope to perform subacromial decompression and then opens up to do rotator cuff repair Uses 3-5 centimeter incision along deltoid along with other portals MINI-DELTOID SPLITTING TECHNIQUE

14. PROS: Preserves deltoid attachment Less soft tissue dissection Provides results similar to open repair Decreased pain Complication rate of 8.8% (Curtis 1992) Quicker rehabilitation protocol CONS: Limited access to joint Risk of deltoid detachment Can be difficult if tear is to large (Lindenfeld 2009) Need for extensive surgical experience (Ellenbecker 2006) MINi-DELTOID SPLITTING PROS/CONS

15. Small incisions of 7-8 millimeters Use anterior portal lateral to coracoid of 5-6 mm. Cannula enters here into glenohumeral joint (Ghodadra 2009) Lateral portal with possible superior lateral accessory portal also. 1 centimeter incision at posterior portal Arthroscopic repair pROCEDURES

16. PROS: Lower risk of complications Improved cosmesis Decreased pain post surgery Avoids deltoid detachment Earlier return to work and sport (Shinners 2002) CONS: Lack of long term outcome data Technical difficulty Fixation method questions Brislin noted complication rate of 10.6% (2007) Arthroscopic pros/cons

17. Yourpracticeonline.com.au/rotator-cuff-tear-3dvideo.html You Tube has several great videos to choose from ARTHROSCOPIC VIDEO

18. SIZE OF TEAR Small tear- less then 1 cm Medium tear 1-3 cm Large tear 3-5 cm Massive tear > 5 cm Full thickness vs. partial tear: Partial can occur on bursal side from subacromial impingement or undersurface from tensile loads and GHJ instability.(Ellenbecker 2006) Full thickness involve top to bottom of tendon. Often occur in supraspinatus (Ellenbecker 2006) OTHER REHABILITATION CONSIDERATIONS-TEAR SIZE If 2 tendons involved will lead to altered stress patterns on GHJ joint but one tendon lesion did not. Tear < 50% debride, > 50% repair Dr. Hasan Multiple studies show that have worse outcome and highest rate of retear with massive tearsIf 2 tendons involved will lead to altered stress patterns on GHJ joint but one tendon lesion did not. Tear < 50% debride, > 50% repair Dr. Hasan Multiple studies show that have worse outcome and highest rate of retear with massive tears

19. Small Rotator cuff tear Source: http://www.bjc-houston.com Small rotator cuff TEAR

20. MEDIUM ROTATOR CUFF TEAR

21. Large rotator cuff tear

22. TISSUE QUALITY: Look at quality of tendon, muscle and bone Thin tissue, soft bone, fatty infiltrate of musculature will all effect rehab speed, (Ghodadra 2009) TYPE OF FIXATION Single row anchors vs. double row Multiple studies show double row repair is stronger OTHER REHABILITATION CONSIDERATIONS Smoking, DM, osteoporosis, previous cancer can all also affect tissue qualitySmoking, DM, osteoporosis, previous cancer can all also affect tissue quality

23. LOCATION OF TEAR- which tendons are involved? SURROUNDING TISSUE QUALITY-what do the other RTC muscles look like? MECHANISM OF FAILURE- Traumatic (3-5%) Gradual wear (95%) How long tear has been present may affect rehab PATIENT VARIABLES- age, activities, general health, work status (Ghodadra 2009) OTHER REHABILITATION CONSIDERATIONS Supraspinatus only typically has smaller sized tears. Posterior shoulder require greater protection. Subscap tear rare-more often with anterior dislocation-more limited ROMSupraspinatus only typically has smaller sized tears. Posterior shoulder require greater protection. Subscap tear rare-more often with anterior dislocation-more limited ROM

24. TYPE OF TEAR- 3 main types Crescent tear-doesn�t retract far and can be fixed directly to the greater tuberosity. Source: Http://www.jaaos.org TYPES OF TEARS-Crescent shaped

25. TYPE OF TEAR- 3 main types U Shaped Tear-Greatest area of tear is longitudinally to the bone. Repair first through margin convergence and then fix the crescent tear to the bone. (Ellenbecker 2006) Source: Http://www.jaaos.org Types of tears-u shaped

26. L shaped tear- one of the leaves (usually posterior) is more mobile and can be brought to the other leaf (Ghodara 2009 and Wilk 1997) TYPES OF TEARS- L SHAPED

27. ACCESS TO CARE SURGEON�S PHILOSOPHY CONSERVATIVE VS. AGGRESSIVE (Ghodadra 2009) OTHER REHABILITATION CONSIDERATIONS

28. Vary based on previously discussed factors Vary depending on SIZE OF TEAR Each surgeon will have their own preferences!! Overall philosophy of progression is fairly similar but the TIMING of progressions can be different ReHABilitation PROTOCOLS

29. Initial protection phase- 0-6 weeks Active Range of motion- 4-6 weeks Strengthening- 8-16 weeks Return to sport- 16 weeks + BASIC GUIDELINES

30. Immediate PROM Flexion may be limited to 90-120 degrees initially ER/IR at 45 degrees abduction to 25-30 degrees initially Elbow, wrist, hand ROM ICE 4-6x/day for 15-20 minutes Patient education KEY!! PENDULUMS: Long et. al studied healthy subjects and found that large correct and large incorrect pendulums both produce maximum voluntary isometric contraction (MVIC) > 15% of supraspinatus and infraspinatus. (2010). INITIAL REHAB DAY 1

31. Continue with PROM to tolerance per guidelines May begin Neuromuscular Stimulation Reinold performed study that showed a 22% peak force production in patients that received NMES vs. those whose didn't (2008). Utilized Empi 300 PV to patient�s tolerance at 10.5�7.1 days postop Start rhythmic stabilization ER/IR at 45 degrees abduction REHAB WEEK 1-2 Positioned at 45 degrees abduction, neutral rotation at 15 degrees horizontal adduction with bolster under distal humerus Pads on infraspinatus Positioned at 45 degrees abduction, neutral rotation at 15 degrees horizontal adduction with bolster under distal humerus Pads on infraspinatus

32. Continue with PROM progressing as indicated Joint mobs begin weeks 3-4 Begin scapulothoracic exercises/scapular clock Smith et. Al (2006) showed that scapular depression and protraction produced MVC < 20% of the supraspinatus, infraspinatus, and deltoid Can do these early in rehab without harm Isometrics-SUBMAXIMAL/PAIN FREE Flex/ER/IR Rehab week 2-4

33. Need to have FULL PROM by week 4-6 Would like to see dynamic humeral head control by 6 weeks Goals of first phase of rehab include restoring ROM, decreasing pain and creating baseline proprioception and kinesthetic awareness (Wilk 2009) Early goals

34. Progressing to AROM Begin with ROM in supine or sidelying (Ellenbecker 2006) DO NOT work through a shrug sign!! Begin basic closed chain exercises Closed chain exercises increases shoulder proprioception, stability and muscle coactivation Start with prayer and quadruped exercises (Uhl 2003) allows for arm to be used in a functional length tension arc with minimal gravitational effects (Ellenbecker) Uhl et. Al demonstrated that these positions are appropriate for earlier rehab phases. EMG showed low activity in all tested musculature-supraspinatus, infraspinatus, anterior and posterior deltoid, and pec major allows for arm to be used in a functional length tension arc with minimal gravitational effects (Ellenbecker) Uhl et. Al demonstrated that these positions are appropriate for earlier rehab phases. EMG showed low activity in all tested musculature-supraspinatus, infraspinatus, anterior and posterior deltoid, and pec major

35. Side lying external rotation (SLER) Reinold demonstrated that SLER produced the highest combined EMG signal for infra and supraspinatus (62 and 67%) Showed increased EMG activity with towel roll placed under arm 20-25% increase in EMG signal with use of towel roll vs. not PNF DYNAMIC STABILITY-TOTAL ARM STRENGTH

36. Full can exercise-best to isolate supraspinatus Reinold (2007)looked at full can, empty can and prone full can exercise. All 3 produced 62-67% of MVIC of SUPRASPINATUS. Demonstrated increased posterior and middle deltoid activity with EMPTY and PRONE FULL can. Prone Rowing- weighted or manually resisted Best exercise per EMG for middle trap (Reinold 2009) Dynamic stability total arm strength

37. Isotonic scapular strengthening exercises PRONE EXTENSION- activates middle and lower trap before the posterior deltoid. Activates middle and lower trap before the upper trap (DeMey 2009). Produced 3rd highest EMG activity in rhomboids and levator per Reinold 2009 PRONE HORIZONTAL ABDUCTION WITH ER- same activation pattern as prone extension per DeMey . Demonstrated 3rd highest upper trap, 2nd highest middle trap, rhomboid, and levator EMG activity per Reinold 2009. PRONE FULL CAN- Highest EMG activity for lower trapezius per Reinold and Ekstrom (97% EMG) and 2nd highest amount of EMG activity for supraspinatus PRONE OVERHEAD ARM RAISE � Ekstrom demonstrated to produce the highest EMG for mid trap (101%) DYNAMIC STABILITY-total arm strength

38. Supine punch at 90 degrees and 120 degrees- Ekstrom demonstrated 62% MVIC of serratus, 3rd highest EMG activation of serratus per Reinold Dynamic Hug Ekstrom demonstrated 53% of serratus activity with this exercise while Reinold rated it the 2nd best exercise for serratus Diagonal shoulder flexion, horizontal flexion and ER Ekstrom demonstrated 100% MVIC of serratus with this activity and is easier for patients with impingement to do. Theraband exercises DYNAMIC STABILIZATION-TOTAL ARM STRENGTH

39. Tripod and pointer exercise-moderate demand on posterior deltoid and infraspinatus (Uhl 2007) Wall pushups with plus- Best exercise for serratus per EMG (Reinold 2009) Wall stabilization with ball Rhythmic stabilization in plank and/or pushup position DYNAMIC STABILIzation-total arm strength

40. Initiate pushup position Demonstrates higher demands on infraspintus, moderate anterior deltoid and pec major activity, while posterior deltoid decreases to low level of activity per Uhl Wall dribbles Body blade Resisted PNF while sitting on ball Planks with theraband/unstable surfaces Pushup stepups Rebounder exercises when allowed Ball flip exercise (Wilk and Payne 2009) Return to activity

41. Focus on using light weights throughout the rehab program Remeasure daily in the passive ROM phase Avoid biceps irritation Develop an appropriate muscle balance with good ER/IR ratio with scapular strength Final thoughts

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