Rotator Cuff Labral Pathology

Rotator Cuff and Labral Pathology: Post-Operative Considerations and Rehabilitation Implementation By Leonard Macrina MSPT, SCS, CSCS

Course Materials

Post-operative Rehabilitation Following Common Shoulder Arthroscopic Procedures

Leonard C. Macrina MSPT, SCS, CSCS Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Course Objectives •

Demonstrate an understanding of the involved anatomy.

•

Recognize the pathomechanics of various shoulder injuries and possible tissue injury.

•

Perform and interpret specific clinical examination tests & maneuvers for the shoulder.

•

Outline a scientifically based post-operative rehabilitation protocol for each glenohumeral lesion, particularly following a repair procedure

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Post-op Guidelines  Rehabilitation program must match surgery  Gradually restore ROM

 Good understanding of the tissues involved  Communication between MD and PT is critical  Continually assess and adjust based on patient

progress  Pain

 End feel  strength

 Favorable outcomes expected



Arthroscopic Repair of: •

Labral lesions –

SLAP II in particular

•

Rotator Cuff Repair

•

Anterior Bankart Repair



Glenoid Labral Lesions Introduction •

•

•

•

Common injury difficult to diagnose May occur in isolation or concomitantly

SLAP lesions: Snyder et al: Arthroscopy ‘90 Andrews: AJSM ’85 Difficult to diagnose – – –

subtle symptoms, pain, popping can cause disability prolonged symptoms Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Anatomy •

Narrow, wedge shaped structure

•

Surrounds periphery of the glenoid

•

Intimately attached to capsule

•

Expect in the anterosuperior aspect

•

Important structure for normal asymptomatic shoulder function Consists of mainly fibro-cartilaginous tissues

•

Bost & Inman JBJS: ‘42 Codman, The Shoulder: ‘34 DePalma, AAOS : ‘49 Gray’s Anatomy : ‘88 Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation




THE GLENOID LABRUM Vascularity •

• •

Originates from suprascapular, circumflex scapular branch of subscapular, & posterior circumflex humeral Mainly peripheral blood supply Superior & anterosuperior less vascularity –

Vascularity decreases with age



Neural Anatomy •

No mechanoreceptors in labrum

•

Free nerve endings in fibrocartilagous tissue of labrum and connective tissue surrounding the labrum

Vangsness: Arthroscopy 1998



GLENOID LABRUM FUNCTION Enhances Static Stabilizers •

Acts as chock block

•

Attachment site of capsule

•

Capsulolabral complex to glenoid - when disrupted there is instability



GLENOID LABRUM Normal Variants •

Buford Complex

•

Cordlike middle glenohumeral ligament attaching to the base of the biceps anchor

•

Absence of labral tissue on the anterior superior glenoid

•

Attachment of MGHL “SLAP repair” will markedly decrease rotation!

• Buford complex: 1.5-5% Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


GLENOID LABRUM Normal VariantsSublabral foramen •

Incidence in shoulder arthroscopies: –

Sublabral 12.0% (73% in MR andforamen: cadaver studies)

•

Normal variants may become pathologic lesions!

•

Do not stabilize normal structures!



Mechanisms of SLAP Lesions



Glenoid Labral Lesions Traumatic Lesions •

Fall onto outstretched arms

•

Forceful abduction diving (diving)

•

Weightlifters

•

Pushing heavy objects –

•

Common in offensive linemen

Blow to the shoulder





Glenoid Labral Tears SLAP Lesions

Type I: Superior labrum frayed Snyder: Arthroscopy, 1990




Type II: Superior labrum detached & frayed Snyder:Arthroscopy ‘90




Type III: Bucket handle tear, displaces into joint Snyder: Arthroscopy ‘90




Type IV: Bucket handle tear displaces, biceps also subluxes into joint Snyder: Arthroscopy ‘90



Glenoid Labral Tears SLAP Lesions •

Type II peel back mechanism

•

Torsional force of biceps labrum as arm abducts & ER

•

Change in biceps vectors from anterior horizontal to vertical & posterior ???



American Sports Medicine Institute ASMI.org

VIDEO



Glenoid Labral Lesions Traumatic Lesions •

Repetitive stresses during throwing (microtraumatic)

•

Anterosuperior lesion, near biceps

• •

•

During follow-through phase *Arthroscopy of 73 throwers 83% exhibited a Labral lesion Andrews, AJSM ‘85 *Throwers undergoing TCS: 91% labral pathology Wilk,Reinold,Andrews:JOSPT ‘02



Miniaci et al:AJSM ‘02 •

Examined 14 asymptomatic professional pitchers

•

Performed MRI & clinical examination

•

79% exhibited abnormal glenoid labrum

•

79% exhibited changes of the supraspinatus tendon

•

Humeral head changes were seen in 36% (cystic changes) Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Glenoid Labral Lesions Degenerative Changes • • •

Due to shoulder mobility and poor blood supply Repetitive stresses lead to tears Significant degenerative labral tears in older individuals – – – –

•

Kohn, Arthroscopy ‘87 106 autopsy specimens 84% degenerative labral lesions 50% exhibited detachment

Clinical implications ???



Maffett et al: AJSM ‘95 •

Mechanisms of Injury: –

Fall onto shoulder

–

Fall onto outstretched arm

– –

Lifting overhead Gradual repetitive lifting

–

Traumatic dislocation

–

Traction force

–

Abduction & ER

–

MVA

–

Insideous

15% 8% 13% 6% 13% 12% 8% 6% 9%



Type V: An anterior-inferior Bankart lesion continues superiorly to include separation of the biceps tendon Maffet: AJSM ‘95



360

Type

•

Avulsion of the glenoid labrum around the entire glenoid – often traumatic mechanism

•

Noticed increased incidence recently –

New protocol



Glenoid Labral Lesions Clinical Examination

•

Clinical examination –

History

–

Physical examination – Specific tests – MRI (enhanced) – Correlate the information Goal is to make the accurate & appropriate clinical diagnosis ! Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


SLAP testing •

Compression Rotation (Grind)

•

Clunk test

•

Biceps load

•

Pronated load

•

Resisted supination with ER

•

Crank



SLAP LESIONS Evaluation •

•

•

Subjective history – May describe single trauma – Fall or during throwing Complaint of pain – Popping,” clicking” , catching – Is clicking + for SLAP lesion ? – “Deep pain within the joint” – Pain with specific movement – Mechanical pain Inability to perform sport at high level Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Glenoid Labral Lesions SLAP Tests • • •

Physical examination PROM & AROM, painful arc of motion Special tests: – – – – – – – – –

Active compression O’Brien: AJSM ‘98 Compression rotation Snyder: Arthro ‘90 Speed’s test Apprehension sign Snyder 40% Grind test Wilk: JOSPT ‘98 Crank test Liu: AJSM ‘96 Clunk test Andrews: AJSM ‘85 Anterior Slide test Kibler: Arthroscopy ‘95 Biceps Load test Kim: AJSM ‘99 Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Test N Sen. Spec. PPV* NPV** Active Compression (18) 33 54 47 55 45 Active Compression (30) 426 47 55 10 91 Active Compression (37) 318 100 99.5 94.6 100 Active Compression (35) 37 78 11 70 14 Active Compression (52) 65 54 31 34 50 Anterior Slide (24) 226 78 92 Anterior Slide (30) 426 8 84 5 90 BicepsLoadII(25) 127 90 97 92 96 CompressionRotation(30) 426 24 76 9 90 Crank (18) 33 39 67 59 47 Crank(28) 62 Crank (35) 36 Crank (52) 65 MRI (5) 52 MRI (8) 46 MR (52) 65 PainProvocation(32) 32 ResistedSupination ER(35) 40 Speed (18) s 33 Speed s (21) 50 ’ ’

* Positive Predictive Value ** Negative Predictive Value

91 35 46 89 89 42 100 83 9 32

93 70 56 91 88 92 90 82 74 75

94 75 41 90 89 63 97 92 30 50

90 29 61

83 64 40 58

Wilk et al: JOSPT ‘05

GLENOID LABRAL LESIONS Active Compression Test O’Brien et al, AJSM 1998 •

Differentiate labral lesions and AC joint abnormalities

•

“Empty can” position, thumb down vs. thumb up

•

Positive test: pain with pronation / extension

•

Sensitivity 100%, specificity 95%



Glenoid Labral Lesions Evaluation • • •

Clinical examination – history Variety of historical features Pain with overhead movements –

• • •

Popping, catching,locking, grinding 50% of patients (Synder: JSES ’95)

History of sudden traction Overhead athletes – change traction Compression fall onto outstretched arm Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


SLAP LESIONS Evaluation • •

Subjective history Chief Complaint: –

Pain

Aching – Loss of strength – Loss of motion – Going out – Stiffness – Weakness –

93% 21% 18% 52% 18% 33% 31%



SLAP LESIONS Evaluation • • •

Subjective history Chief Complaint: PAIN Pain Magnitude: –

Slight pain: 1% – Only after activity 10% – Only during specific activity 99% – Moderate pain: 51% 49% – Marked Pain: – Complete disability: 3% Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


SLAP Lesions Surgical Treatment •

Type I: Debride back to stable rim

•

Type II: Reattach superior labrum to glenoid, stabilize biceps anchor

•

Type III: Torn fragment resected, leave remaining stable tissue

•

Type IV: Treatment base on extent of biceps tear –

Less than 30%: torn tissue resected – Greater than 30%: biceps repair (age)



Type II SLAP Before Repair Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Type II SLAP After Repair Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


SLAP Lesions Rehabilitation Guidelines



JOSPT May 2005



SLAP Lesions Rehab Guidelines •

Rehabilitation must match the surgery –

•

Repair vs. Debridement

Based on type of lesion –

SLAP classification I thru IV

•

Emphasis on dynamic stabilization

•

Do not overstress healing tissue

•

Minimize biceps activity (II, IV)

•

Microtrauma injury – *think dynamic stabilization !!!



Rehab Following SLAP Repair with Concomitant Surgical Procedures  SLAP repair with stabilization surgery Thermal capsular shrinkage Bankart repair (type V) Capsular shift or plication

 SLAP repair with cuff repair Arthroscopic or open repair

 SLAP repair with decompression  SLAP with debridement Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Rehabilitation Following SLAP Repair Overview • • • •

Concern is to control forces/loads on repaired labrum ER/IR motion usually Not a problem no excessive motion for 8 wks* Restoration of full arm elevation (flexion) sometimes difficult Determine extent of lesion* – –

•

Number of suture anchors used Location of lesion

Ensure dynamic stability is present Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Rehabilitation Following SLAP Repair Precautions •

Control forces for 6-8 weeks

•

No overhead movements (above 90) for 3-4 weeks

•

Need stable glenohumeral joint

•

Emphasize dynamic joint stability –

•

Minimize GH translation

No isolated biceps 8 weeks –

No heavy lifting



Rehabilitation Following SLAP Repair Precautions •

No CKC exercise drills until 8 weeks post-op

•

No resisted movements above 90 degrees elevation for 8 weeks

•

No heavy bench press, heavy lifting overhead until 3 months post-operative Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Rehabilitation Following SLAP Repair Weeks 1-3 •

Sling for 3-4 weeks –

•

Immediate “limited motion” – –

•

AAROM / PROM flexion Weeks 2-4: flexion to 90 to 70 ~ 300 Abduction

Isometrics (all planes) –

•

0

AAROM ER/IR in scapular plane –

•

Sleep immobilizer 4 weeks

No isolated Biceps

Isotonics week 2 (active ROM )



Rehabilitation Following SLAP Repair Weeks 3-4 • •

Remove ROM restrictions Gradually increase ROM –

Flexion to tolerance

 ER/IR at 900 ABD •

Full ROM @ week 7-8 – –

•

ER @90 abd to 95-105 in overhead athletes

Progress isotonic strengthening program –

“thrower’s ten program”



Why is the Rotator Cuff Important? •

Dynamic stabilizers –

Rotator Cuff •

Center humeral head into concave glenoid fossa during upper extremity motions

•

Vital in arthrokinematics

•

Appropriate muscle strength and balance

•

Pathology results in inefficiency





Rehabilitation Following SLAP Repair •

Full ROM by week 6-9  ER to 900 by week 6-7  ER to 1050 by week 7-8  ER to 115 at week 10-12

•

Plyometrics week 8 – 2 hand plyo’s week 8-10 –

• •

No CKC drills for 8-10 weeks Isolated biceps: initiate week 8 –

•

1 hand plyo’s week 12

Light & progress

Machine weights –

Week 12 Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Intermediate Phase •

OK to initiate AROM activities ~6 weeks – –

ER/IR tubing at 0° abduction Scapula strengthening • • • •

•

Prone rowing Prone extension Scapula retractors Scapula depressors

Continue with rhythmic stabilization drills

Caution against long lever arm motions!!



Macrina Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation




Advanced Phase Week 12-16 •

Goals: –

Maintain ROM/flexibility

–

Progress strengthening

–

Gradual application of functional loads

–

Gradual return to full activities





2-handed Plyos… Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


One handed plyo’s...



Return to Activity Phase • •

•

Continue strengthening exercises Initiate interval throwing program (ITP) –

Quarterback

–

Reinold et al JOSPT 2002

Return to competition ~6 months –

Contact sports



Rehabilitation following rotator cuff repair Introduction – – –

Common pathology in orthopaedic setting Functionally debilitating Common mechanism • • •

–

Traumatic Traumatic with underlying tissue weakness Gradual onset due to weakening, overuse

Overhead athletes • •

Spectrum ranges from pitchers to position players Generally very different in onset



Clinical Presentation •

Symptomatic complaints with active elevation

•

Resting or night pain

•

Pain with resisted ER and/or elevation

•

Feeling of “dead arm”

•

Pain with late cocking → follow thru

•

Traumatic dislocation



Differential Diagnosis • • • • •

Impingement syndrome Bursitis C-spine involvement Frozen shoulder Labral pathology



Rotator cuff testing •

Hawkin’s/Kennedy

•

Neer’s

•

Active elevation

•

Passive IR with elevation

•

Internal impingement sign –

With reposition test Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation



Empty can

•

Full can

•

Drop arm

•

Lag sign

•

Lift off

•

Belly press




Empty can

•

Full can

•

Drop arm

•

Lag sign

•

Lift off

•

Belly press




Empty can

•

Full can

•

Drop arm

•

Lag sign

•

Lift off

•

Belly press




Empty can

•

Full can

•

Drop arm

•

Lag sign

•

Lift off

•

Belly press




Empty can

•

Full can

•

Drop arm

•

Lag sign

•

Lift off

•

Belly press



Rotator cuff testing • • • • • •

Empty can Full can Drop arm Lag sign Lift off Belly press –

–

More likely to detect tear in upper fibers Tokish JSES 2003



How accurate are MRI’s? Sher et al JBJS Am 1995 • MRI on 96 asymptomatic shoulders • Overall, 33 with RTC tears (34%) – –

•

If >60 yrs. old –

•

14 full thickness (15%) 19 partial thickness (20%) 54% had abnormal MRI

If 40-60 yrs. old –

28% had abnormal MRI Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Why so significant?



Biomechanics and Implementation of Shoulder Rehabilitation •

Dynamic stabilizers –

RTC •

Center humeral head into concave glenoid fossa during upper extremity motions

•

Vital in arthrokinematics

•

Appropriate muscle strength and balance

•

Pathology results in inefficiency




Morrey, Itoi et al (1998 Rockwood & Matsen)

•

•

Deltoids produced superior vector 0-90° butforce compressive 120-150° SS- consistent compressive force throughout full ROM



Post-op considerations 7 Key factors 1.

Type of repair •

2.

Concomitant procedures – – –

3. 4. 5. 6. 7.

Arthroscopic vs. mini-open SLAP repair SAD Capsular involvement

Size of tear Tissue quality Age of patient Length of time from surgery Ultimate functional goals • •

Positional player Starter or reliever



Post-op RTC repair •

Keys to treatment –

Re-establish capsular mobility •

Inferior and anterior capsule

–

Re-establish humeral head control (dynamic stability)

–

Good muscular balance •

–

ER/IR ratio

Do not work through shrug



Post-op keys –

Create movement environment immediately!! • •

–

Pulleys

•

L-bar PROM

•

Pendulums

•

Joint mobs

Prevent excessive scarring, capsular restrictions



Communication with physician is critical for successful outcome!!



Post-op issues •

Surgical & rehabilitation –

Infection

–

Poor capsular mobility

– –

Spasm or hard end-feel Significant pain

–

Over-aggressive

–

•

Too early AROM or strengthening

•

Retear the repair

Unable to return to previous level of function



Classification •

Small

< 1cm

•

Medium

1-3 cm

•

Large

3-5 cm

•

Massive

> 5 cm



Protocols We use 3 types of protocols Type I: small tear with excellent tissue quality Type II: medium to large tear with good tissue Type III: large to massive tear with poor tissue



The rehabilitation must match the surgical procedure!!



Overhead Athlete •

More aggressive –

Younger patient

–

Greater healing potential

–

Better tissue quality

–

Functionally demanding outcomes

–

Trend toward arthroscopic approach



Overhead Athlete •

Arthroscopic vs. Mini-open approach –

Minimize tissue involvement •

Deltoid sparing

–

Decreased scar tissue formation

–

Decreased pain

–

Similar fixation strength with improved technology

–

Trend toward all arthroscopic repair •

Nearly 100% in overhead athlete Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Functional Outcomes •

Mazzoue, Andrews AJSM 2006 –

16 professional baseball

–

players Full thickness RTC tear

–

Mini-open approach

–

12 pitchers, 4 position

–

Only 1 pitcher (8%) returned to competition Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Risk factors for recurrent tears •

•

•

Size of Tear –

Ide: Arthroscopy ’05

–

Sugaya: JBJS ’07- 40% retear rate

–

Verma: Arthroscopy ’06

Age of Patient –

Boileau: JBJS ’05- 29% failure rate

–

Liem: JBJS ’07

–

Lichtenberg: Knee Surg Spts ’06

–

Cho: Clin Orthop Surg 2009- 22.5% retear rate

Occupation –

•

Gazielly: Rev Chir Orthop Repar ’95

Tissue Quality, early activities, too aggressive Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Cho et al 2009 Healing rates •

<50 years of age (49 shoulders) –

•

•

–

•

65.4%

•

96.7%

medium-sized tears (71 shoulders) –

79.4%

>61 years of age (52 shoulders, p = 0.049)

small-sized tears (30 shoulders) –

87.8%

51-60 years of age (68 shoulders) –

•

87.3%

large-sized or massive tears (68 shoulders –

58.8%



Outcomes •

Jones & Savoie Arthroscopy 2003 –

60 patients with large or massive tears •

37 large

Average follow-up 32 months – 88% with good or excellent results –

–

No difference in outcomes of massive vs. large tears



Outcomes •

Bennett WF –

Arthroscopy 2003

–

24 full thickness supraspinatus tears only

–

Small to medium size tears

–

Improved ASES score from 29 (pre-op) to 82 (post-op)



Outcomes •

•

Cho et al 2009 –

169 consecutive aRTC repairs

–

Mean age 57.6 y.o.a

–

Mean f/u 39.6 months

Per MRI- RTC completely healed in 77.5% of shoulders



Outcomes •

Youm et al JSES 2005 –

84 patients underwent RTC repair surgery – 42 arthroscopic repairs (21 small, 9 medium) – 42 mini-open (17 small, 23 medium) – Average follow-up 36 months (range 24-70 months) – No significant difference in outcomes between 2 surgery types – Outcomes measured VAS pain and functional improvement



Morse et al AJSM Sept. 2008 •

Meta-analysis

•

Arthroscopic vs. mini-open RTC repair –

5 studies met inclusion criteria • • •

•

Level III evidence or better Minimum 1 year f/u Validated functional scores (ASES, Constant, UCLA, SST)

No difference in functional outcomes or complications between 2 procedures Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Arthroscopic Type II •

Immediate post-op phase –

Re-establish full PROM

–

Diminish pain/inflammation

–

Minimize atrophy

–

Do not over-stress healing tissues!

–

Protect healing tissues •

Abduction pillow for 4 weeks



Immobilization



Best position for Immobilization?? •

Hatakeyama et al AJSM 2001 –

Strain on RTC repair in various positions

–

0, 15, 30, 45° elevation in coronal, sagittal,

scapula plane – Also from 60° int. rotation to 60° ext. rotation

Scapula Plane

Results Hatakeyama et al AJSM 2001 Coronal Plane

Sagittal Plane



Post-operative Phase Week 1 • •

Sling or abduction pillow PROM – –

• • • • •

ER/IR in scapula plane flexion to tolerance

Pendulums Pulleys in scapula plane ER/IR AAROM with L-bar Submaximal, gentle isometrics with NMES Cryotherapy




•

EMG of supraspinatus during PROM & AAROM activities Dockery et al Orthopedics 1998 10 healthy subjects – MVIC supraspinatus during common post-op activities – PROM elevation <5% MVIC – L-bar flexion 8.3% MVIC – Pulleys 17.6% MVIC –



Park, Idjadi, ElAttrache et al AJSM 2008 •

Biomechanical testing of 6 cadaveric RTC Repairs

•

Compared suture bridge technique to double row repair technique

•

Cyclically loaded from 0 to 60 N – Constructs loaded to failure

•

Also, compared neutral to ER (0-30) PROM

•

Suture bridge technique significantly stronger – 161N to 135N

•

ER produced increase tension anterior supraspinatus – relaxed posterior aspect of supraspinatus Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Biomechanics and Implementation of Shoulder Rehabilitation

•

We believe it’s safe to initiate PROM & AAROM activities immediately following RTC repair surgeries



Post-operative Phase NMES following RTC repair (Reinold, Macrina, Wilk et al) –

AJSM Dec. 2008

–

39 subjects (mean age 50 years old)

–

2 mini open & 37 scopes

–

Average size of repair was 2.8 cm

–

Significantly greater force production with NMES than without (3.27 kg vs. 2.49 kg)



Post-operative phase Week 2-4 •

Continue PROM to tolerance

•

Pulleys in scapula plane

•

Initiate AAROM flexion with

•

L-bar Full PROM by week 4

•

ER to 90° week 4

•

Continue isometrics with NMES



Post-operative Phase Re-establish dynamic stabilization –

Isometrics with NMES

–

Rhythmic stabilization drills •

Supine 45° abduction

•

Supine 100° flexion, 20° horiz. abd. –

Remember muscle force vectors

–

Deltoid will assist in humeral head compression above 100° flexion



Rhythmic Stabilization



Intermediate Phase Weeks 4-8 Goals: –

Maintain full PROM

–

Protect healing tissue

– –

Establish dynamic stability Re-establish muscular balance

–

Re-establish balanced capsular mobility

–

Progress strengthening activities

–

Minimize pain Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation



Continue with ROM –

PROM, AAROM AROM

•

ER at 90° abduction to 110-120°

•

IR at 90° abduction to 60°



Post-operative phase Weeks 4-6 • Gradual progression in strength –

–

–

•

Initiate ER/IR tubing with NMES Initiate scapula strengthening Continue isometrics

Must obtain full PROM –

Gentle joint mobs as needed




OK to initiate AROM activities ~6 weeks – –

ER/IR tubing at 0° abduction Scapula strengthening • • • •

•

Prone rowing Prone extension Scapula retractors Scapula depressors

Continue with rhythmic stabilization drills

Caution against long lever arm motions!!



Gravity minimized flexion



Intermediate Phase Week 6-10 • ER at 90° abduction to ~115-120° • Progress to Thrower’s Ten exercises •

Stabilization exercises – –

•

Wall push-ups Wall stab’s

Emphasis on manual resistance, endurance with eventual eccentrics



Wall stabilization drills



Manual resistance





Advanced Phase Week 10-16 •

Goals: maintain repair integrity

•

Gradually increase strength

•

Initiate light functional activities

•

Stress the tissue



Advanced Phase •

Continue Thrower’s Ten program –

•

Initiate plyometric activities – –

•

Progress 1 lb every 7-10 days

2-hand @ week 12-14 1-handed week 14-16

Initiate interval hitting program for position players



2-handed Plyos… Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


One handed plyo’s...



Return to Activity Phase Week 16-22 •

Goals: –

Maintain ROM/flexibility

–

Progress strengthening

–

Gradual application of functional loads

–

Gradual return to full activities



Return to Activity Phase • • •

Continue Thrower’s Ten exercises Initiate interval throwing program (ITP) Reinold et al JOSPT 2002 Phase I ~16-20 weeks – Phase II ~24-26 weeks –

•

Return to competition ~8-12 months



Rehabilitation following Shoulder Stabilization procedures Introduction • •

Very common in outpatient rehabilitation Often treated without surgery with good results –

•

•

Return to prior function without limits – Dependent on many factors Surgical intervention warranted if continued limits in function and/or stability Rehabilitation must match surgical procedure Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Shoulder Instability •

Various types –

Acute • Anterior • posterior

–

MDI • Congenital Acquired laxity • Due to repetitive stresses • Overhead athlete • Micro-instability • Internal impingement

–



Key Factors •

Direction of instability –

–

–

Anterior • Most common (98%) • Bankart Lesion • HAGL lesion – Humeral avulsion IGHL complex • Micro-instability Posterior (~2%) • Football lineman • FOOSH • Mair AJSM 1998 – 8/9 posterior episodes were offensive lineman – 75% required surgical stabilization MDI • Congenital laxity



Non-op Instability Wilk, Macrina NAJSPT Feb. 2006

1. Onset 2. Degree 3. Frequency 4. Direction 5. Other tissues involved 6. NM control status 7. Functional goals



Immobilization •

Acquired- almost never

•

Traumatic- older patients, sometimes –

No long term benefits from immobilization • •

Hovelius JBJS 1987 Kiviluoto Acta Orthop Scand 1980

–

Protect healing tissue

–

Allow scar formation



Immobilization •

In what position?

Itoi et al JBJS 2002 Itoi et al JSES 2003

Improved capsular healing and 0% recurrence rate at 30 ER °



Immobilization •

Factors that affect re-dislocation rates –

Age •

Hovelius JBJS 1996

•

20 years or younger- 85% recurrence rate 40 years or older- 15% recurrence rate

•

–

Activity level

–

Recurrence •

Within 2 years



Key Factors •

NM control –

Motor reaction to sensory input – Detect joint position in space with motor response

to• assist in dynamic humeral head stabilization Lephart JSES 1994 •

Wilk JOSPT 1997

–

Particularly at end range – Poor NM control- excessive HH migration •

Injury results



Key factors •

NM control –

Lephart JSES 1994 •

Compared ability to detect PROM and active joint reposition

•

–

Normal

–

Unstable

–

Surgically repaired

Diminished proprioception in unstable shoulder compared to other 2 groups



Key Factors •

NM control –

Smith & Brunoli Phys Ther 1989 •

–

Significant decrease in proprioception following dislocation

Zuckerman JSES 1999 •

Diminished proprioception with age



Definitions Laxity – – –

•

Assessment of joint displacement Large range of translation Allows for functional activities

Instability –

Excessive joint translationimpedes patient from performing functional activities • • •

Sports ADL’s Etc…



Onset of instability Acute •

Traumatic –

fall onto outstretched hand

–

Football lineman •

–

Posterior instability

Excessive horizontal abduction •

Esp. with external rotation



Don’t stretch a patient with underlying congential laxity



Shoulder Instability Decision Making History Physical Examination Radiographs CT/MRI

1st Time Dx

D ia g n o s is

In/Out Season? Patient at Risk

EUA/Arthroscopic Findings Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Operative Strategy/Priority •

1 s t Priorit y: LA B RU M

•

2 n d Pri ority:

•

Ca ps ule

3 rd Pri ority: Rota tor Interval



Surgical options •

Bankart Repair –

Open – Arthroscopic • •

• • • •

Anterior Posterior

Capsular shift Plication Laterjet procedure Thermal capsular shrinkage –

Not as common Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation




Capsular Suture Plication •

Anterior

•

Posterior

•

Both



Laterjet/Bristow Technique



Shoulder Surgery Position

Beach Chair

Lateral Decubitus



Concomitant procedures •

Rotator cuff repair

•

Rotator cuff debridement

•

SLAP repair

•

Subacromial decompression

•

Labral debridement



Rehabilitation Following Shoulder Stabilization Rehab Philosophy  Understand type & nature of lesion 

traumatic congenital  Understand type of surgical procedure  Rehab must match the surgery & patient*  Isolated Lesion Concomitant lesion  Evaluate/grade patients’ tissue status  Never overstress healing tissue

**Assess end feel**  Avoid effects of immobilization  Gradual increase applied forces/loads  Recognize fixation strength & healing rates Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Shoulder Stabilization Rehab

Mobility

Stability



Post-op principles 1. Type of repair •

Arthroscopic vs. open

2. Location of tear/instability –

Anterior

–

posterior

3. Tissue quality – –

Generalized capsular laxity throughout Chronic vs. acute

4. Age of patient 5. Length of time from surgery 6. Ultimate functional goals Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Open Bankart Repair ROM Guidelines •

Week 1: –

•

Week 2: – –

•

0-100° flexion ER/IR at 45° abd scapular plane: 0-25°

Week 3-4 – – –

•

0-90° flexion

Flexion to 120-140° ER at 45° abd. scapular plane: 35-45° IR at 45° abd. in scapular plane to 45-60°

Week 5-6: Flexion to 160° (tolerance) –

ER/IR at 90° abduction: • •

•

IR to 75° ER to 70-75°

Beyond 6-8 weeks progress as tolerated Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


ROM Principles •

Rate of ROM progression based on: • Amount of motion present • End feel assessment • Capsular • Hard Open • Degree of congenital laxity present • Which shoulder dominant? • Functional goals • Overhead athlete • Function below shoulder height • Contact sports •



Guidelines Arthroscopic/Open repair •

Sling for 2-3 weeks

•

Sleep in immobilizer for 4 weeks

•

Elbow/hand ROM

•

Hand gripping exercises



Arthroscopic Bankart Repair ROM Guidelines Passive and gentle active assistive ROM exercise • Week 1: –

•

Flexion to 70°

Week 2: –

Flexion to 90°

–

ER/IR with arm 30° abduction • •

•

ER to 5-10° IR to 45°

Week 3-4: – – –

Flexion to 100° ER in scapular plane to 15-20° IR in scapular plane to 55-60°



PROM



Progress ROM •

Weeks 5-6: – – –

•

Weeks 7-9: – – – – –

•

Flexion to 145° ER at 45° abduction: 45-50° IR at 45° abduction: 55-60°

Flexion to 160° Initiate ER/IR at 90 ° abduction ER at 90° abduction: 70-80° at week 7 ER to 90° at weeks 8-9 IR at 90° abduction: 70-75°

Avoid excessive ER, extension and horizontal abduction





Strengthening Guidelines Arthroscopic Bankart Week 0-2 Submaximal/painfree isometrics for • shoulder musculature Rhythmic stabilization drills ER/IR • Proprioception drills • • No IR strengthening for 2-3 weeks (open repair only) Week 3-4 Continue as above • Initiate light isotonics for shoulder • musculature Tubing for ER/IR • Abduction, full can, sidelying ER, prone • rowing, biceps Initiate scapula strengthening •





Strengthening Guidelines Bankart repair Week 5-6 • Progress exercise tubing ER/IR (arm at side) •

Scapular strengthening PNF manual resistance Week 7-9 • Continue to progress isotonic strengthening program •

–

•

Thrower’s Ten

Continue PNF strengthening Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Strengthening Week 10-16 •

Continue strengthening exercises

•

Progress Throwers Ten program (for overhead athlete)

•

Isotonic strengthening for entire shoulder complex

•

PNF manual technique

•

Neuromuscular control drills Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation






Bankart Repair Week 10-14 • Continue all flexibility exercises • Continue all strengthening exercises • Two hand plyometrics – – –

•

One hand plyo’s Week 12-13 – –

•

Chest pass Overhead Side to side 90/90 Dribble

May initiate light isotonic machine weight training (week 12-14) Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation










Functional Guidelines •

Initiate interval sport program ~ week 16

•

Return to contact sports 4-6 months

•

Return to overhead athletics 6-9 months Gradual return to mound throwing



Karlsson, et al AJSM ‘01 • • • • • •

Comparison open vs. arthroscopic Bankart repairs GC arthroscopic repair (Suretac) v. 53 open (anchors) Follow-up average 28 months Recurrence rate: arthroscopic 15%, open 10% Rowe score: arthroscopic 93 points, open 89 points Only significant difference ER @ 900 abd: Arthroscopic: 900 (50-1350) Open: 800 (25-1150)



Open Bankart Procedures •

Results vary somewhat

•

92-97% good – excellent results

•

Loss of motion is common –

•

Especially external rotation

Some long term studies indicate recurrent instability 17% Magnusson: AJSM ‘03



Arthroscopic Bankart Procedures •

Results vary somewhat

•

85-95% good – excellent results

•

Loss of motion is uncommon

•

Recurrent instability is slightly higher than with an open Bankart procedure

Rockwood & Matsen: The Shoulder ‘01 •

Long term results 95% G-E results, slight LOM Kim: JBJS ‘03



Kim:Arthroscopy ‘03 •

Prospective randomized study Bankart repair

•

Arthroscopy Bankart in 62 pts (mean age 28)

•

Group I: immobilized for 3 weeks

•

Group II: immediate staged rehab

•

Follow-up average 31 months

•

Recurrence rate: no difference…<3%

•

Final outcomes: no significant differences



Bottoni, Smith, et al: AJSM ‘06 • • •

• •

Arthroscopic vs open Bankart Surgery Follow-up 32 mos Operative time: –

Open: 149 mins.

–

Arthroscopic: 59 mins.

–

Avg. loss compared to opposite shoulder ER ROM: open 6.6 + 7.7 deg ER ROM: arthroscopic 2.0 + 3 deg

Failures: 2 open & 1 arthroscopic LOM: greater loss in open group – –

•

Subjective scores equal between groups Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Rehabilitation Following Posterior Bankart Repair •

Slower progression of ROM & function –

Brace (immobilizer) for 6 weeks

–

Limit IR, horizontal adduction

•

Delay push-ups, bench press, pushing motions for 12-14 weeks

•

Monitor posterior laxity

•

Emphasize ER strengthening and scapular strengthening

•

Return to sports 9-12 months Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation


Ultrasling ER • •

•

DonJoy ER 15/30° ROM exercises usually begins at 4-6 weeks postoperative Much More conservative than anterior



Summary Successful outcomes dependent on: • Type of surgery • Tissue quality • • •

•

Size of tear Gradually restore ROM Re-establish dynamic stability & neuromuscular control Communication with MD!!!



Rotator Cuff and Labral Pathology: Post-Op

Bibliography MedBridge Education Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation Lenny Macrina, MSPT, SCS, CSCS

1.

Fleisig GS, Bolt B, Fortenbaugh D, Wilk KE, Andrews JR. Biomechanical comparison of baseball pitching and long-toss: implications for training and rehabilitation. J Orthop Sports Phys Ther. 2011;41(5):296-303.

2.

Lintner D, Mayol M, Uzodinma O, Jones R, Labossiere D. Glenohumeral internal rotation deficits in professional pitchers enrolled in an internal rotation stretching program. Am J Sports

Med. 2007;35(4):617-621. 3.

Mazoue CG, Andrews JR. Repair of full-thickness rotator cuff tears in professional baseball players. Am J Sports Med. 2006;34(2):182-189.

4.

Reinold MM, Macrina LC, Wilk KE, Dugas JR, Cain EL, Andrews JR. The effect of neuromuscular electrical stimulation of the infraspinatus on shoulder external rotation force production after rotator cuff repair surgery. Am J Sports Med. 2008;36(12):2317-2321.

5.

Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises.J Athl Train. 2007;42(4):464-469.

6.

Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players.Am J Sports Med. 2008;36(3):523-527.

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Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329-335.

8.

Wilk KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability.N Am J Sports Phys Ther. 2006;1:16-31.

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Wilk KE, Reinold MM, Macrina LC, et al. Glenohumeral Internal Rotation Measurements Differ Depending on Stabilization Techniques.Sports Health Journal. 2009;1(2):131-136.

Rotator Cuff Labral Pathology

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