rotator cuff repair

ROTATOR CUFF REPAIR & Physiotherapy REHABILITATION:

ROTATOR CUFF REPAIR & Physiotherapy REHABILITATION DR. DIBYENDUNARAYAN BID

THE ROTATOR CUFF:

THE ROTATOR CUFF Complex of 4 muscles: Supraspinatus, Infraspinatus, Teres minor and Subscapularis). Their role is to assist in the stability of the shoulder, rotate the shoulder and act as a humeral head depressor during shoulder elevation and abduction.

Making sense of impingement:

Making sense of impingement

Rotator Cuff Muscles:

Rotator Cuff Muscles 3 originate on posterior scapula (S I T) 4th originates on anterior scapula Teres Minor Infraspinatus Supraspinatus Subscapularis

Stabilizing Influence of Rotator Cuff:

Stabilizing Influence of Rotator Cuff muscles have a large stabilizing component when active all have a ‘large’ horizontal component so play a significant role in stabilizing the humerus against the glenoid fossa

Rotator Cuff Impingement:

Rotator Cuff Impingement impingement of supraspinatus tendon 2 theories GENETIC : too narrow a space between acromion and humeral head OVERUSE : repeated stretching of supraspinatus weakens its ability to stabilize the humerus leading to deltoid pulling humerus up and impingement of tissues

DEFINITION OF IMPINGEMENT:

DEFINITION OF IMPINGEMENT Matsen & Arntz (1990) defined impingement as “ the encroachment of the acromion, coraco-acromial ligament, coracoid process &/or acromio-clavicular joint on the rotator cuff mechanism that passes beneath them as the glenohumeral joint moved, particularly in flexion and rotation”.

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This impingement causes friction centered on the supraspinatus that may extend to the infraspinatus and the long head of biceps. This friction may eventually result in degenerative tear of rotator cuff tendon. Thus impingement is a continuum ranging from inflammation or degeneration of the sub-acromial structures to partial or complete tears of the rotator cuff.

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Neer (1972) described the pathology of impingement syndrome into three stages: Stage I : Edema & hemorrhage usually in young athletes involved in overhead sporting activities. Stage II : Thickening & fibrosis with a possible rotator cuff tear. Stage III : Tendon degeneration and complete rotator cuff tear.

Making sense of impingement:

Making sense of impingement Anatomical abnormalities (e.g. beaked acromion) Poor scapular control Anterior instability Excessive load on rotator cuff muscles Posterior capsule tightness Elevation of humeral head Imbalance between humeral head elevators and depressors Rotator cuff weakness Encroachment from above Inferior movement of acromion Anterosuperior translation of humeral head Narrowing of subacromial space Swelling of rotator cuff tendon Impingement with exercise Rotator cuff tendinitis Instability Abnormal biomechanics Overuse

Figure X- Avulsion of bone from the tuberosity:

Figure X- Avulsion of bone from the tuberosity

Figure 4 - Major episodes of tendon tearing:

Figure 4 - Major episodes of tendon tearing

Figure 6 - Degenerative lesions of the cuff generally start at the deep surface of the anterior insertion of the supraspinatus near the long head of the biceps:

Figure 6 - Degenerative lesions of the cuff generally start at the deep surface of the anterior insertion of the supraspinatus near the long head of the biceps

Figure 11 - Infraspinatus and teres minor tear:

Figure 11 - Infraspinatus and teres minor tear

Figure 12 - Destabilization of the long head tendon of the biceps:

Figure 12 - Destabilization of the long head tendon of the biceps

Indications of Rotator cuff repair:

Indications of Rotator cuff repair Symptomatic tear of rotator cuff; and When conservative management has failed. Most commonly Supraspinatus is ruptured. Rupture occurs almost always through a degenerative process, although traumatic rupture is possible. A minor fall may cause an acute tear of a previously degenerate tendon.

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The patient presents with a combination of pain weakness and restriction of movement. The pain is characteristically on movement, but may occur at rest and night with larger tears. Examination may reveal typical painful arc &, in more substantial tears, there may be evidence of weakness of either the supraspinatus or infraspinatus muscles.

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In patients with relatively mild symptoms, arthroscopic decompression may be chosen to see if this relieves the pain, therefore precluding the need for more major open surgery. It is advisable for young patients to have a rotator cuff repair even if their symptoms are not severe, because of the possibility of the tear extending.

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It must be assumed that large tears were once small. In the frail and elderly, an arthroscopic decompression may be preferred because of the much lower risk to the patient and faster recovery rate.

Figure 9 - Full thickness defect:

Figure 9 - Full thickness defect

INVESTIGATION:

INVESTIGATION History taking Clinical examination X-ray Ultrasonography & MRI

Technique :

Technique Beach chair position A superior strap incision is made over the lat border of acromion, exposing the ant edge of the acromion and the junction of the ant third and post two thirds of the deltoid muscle. This muscle is than split in the line of its fibers, detaching the deltoid from the ant portion of the acromian. This exposes the coraco-acromial ligament, which is released from the front edge of the acromian. The anterior edge of the acromian is then excised.

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The rotator cuff is then exposed and the extent of the tear defined. Once the tear has been assessed and the bursal tissue overlying it excised and debrided, then the thickness and quality of the residual cuff muscle are evaluated.

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Small tears less than 3 cm usually involve part of the insertion of the supraspinatus and can be relatively easily drawn back down onto the greater tuberosity. These tears are repaired by inserting them in a groove cut in the upper surface of the greater tuberosity, and are attached using bone sutures. The bone sutures draw the rotator cuff in that position.

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For medium sized tears of 3-5 cm, some dissection of the rotator cuff may be necessary to allow them to be drawn back down onto the greater tuberosity. The size of the cuff does not always determine its ease of repair and some medium-sized tears can be very difficult to repair because they have become rigid & inelastic. Nevertheless, it is usually possible to repair a medium-sized tear, and this is undertaken in a similar fashion to smaller tears using a groove cut in the greater tuberosity and intraosseous sutures. (Fig 10.7 A & B)

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The medium sized tear of 3-5 cm may take on either a “U” or an “L” shape. In the latter shape, the tear not only involves the whole of the supraspinatus, but also extends along the rotator interval (Fig. 7.11 A&B). In the former shape, both the subscapularis and, more commonly, the infraspinatus may begin to be involved (Fig. 7.12 A, B & C). In this type of tear it may be impossible to draw the supraspinatus back down onto the greater tuberosity, and therefore it may be necessary to transfer either the upper part of the supraspinatus or whatever remains of the infraspinatus onto the greater tuberosity (Fig.7.13).

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In the ‘L’ shaped tear, it may be possible to close side to side the rotator interval and some remaining part of the supraspinatus. Another option is to include the biceps tendon in the repair, performing a tenodesis of this tendon to what ever remains of reparable rotator cuff. Some surgeons will use suture anchors if they find the greater tuberosity too osteoporotic. Once the rot cuff has been repaired, the bursa is closed, if possible, over it.

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The subsequent closure is identical to that of the ant acromioplasty, with interrupted sutures to the deltoid and then closure of the skin.

POSTOPERATIVE MANAGEMENT:

POSTOPERATIVE MANAGEMENT It is best to repair he rot cuff so that the arm can be left by the side without placing undue tension on the repair. In 90% of cases, this is possible, and only rarely does some form of abduction splint have to be used (7.14). Passive mobilization should begin immediately and instruction given for mobilization exercises for the elbow, wrist and neck. During the first 2 weeks after surgery, no active movement should be allowed, although pendulum movements and passive flexion in extension should be encouraged to prevent any postoperative stiffness.

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After 3-4 weeks, further passive movements should be encouraged and some passive assisted exercises commenced. Active work does not usually begin until 6 or 8 weeks. The precise nature of the program will depend on the size and security of the rot cuff repair, and to this end it is important to liaise with the surgeon.

Complications :

Complications Generally, 80% of patients who have their rot cuff repaired will have good relief of pain and improvement in strength by 6 months. There is a tendency for the rot cuff to re-rupture and this re-rupture rate may be up to 30%. Even if the cuff does re-rupture , the ant acromioplasty may still afford some relief of pain. Infection is always a concern with this type of surgery and any increase in pain or abnormal redness in the area should be taken very seriously. Postoperative stiffness

PRINCIPLES OF REHABILITATION :

PRINCIPLES OF REHABILITATION The main goals of rehab after repair of the rot cuff are to: Decrease or remove pain. Increase muscle strength and Control. Increase functional activity. Increase ROMs.

Three stages of rehab will be followed- namely, early passive motion, stretching and Strengthening.:

Three stages of rehab will be followed- namely, early passive motion, stretching and Strengthening. Early passive motion Early mobilization is desirable as it prevents the formation of adhesions. However, care must be taken not to disrupt the integrity of the reconstruction or delay the healing process. The tendinous insertion of the muscle should be protected against active muscle contraction for about 6 weeks. Gentle passive ROM exercises, however, may be commenced as early as the first post op day.

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Stretching Stretching prevents the formation of adhesions, and should initially be gentle and passive. In the later stages of rehab, vigorous stretching, both actively and passively, may occur.

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Strengthening Strengthening starts with simple isometric contractions progressing to active assisted movements and then movements against gravity. Progressive resistance is added until normal strength is attained. Improvements in strength may continue for up to 2 years after shoulder surgery.

CONTRAINDICATIONS:

CONTRAINDICATIONS Following rot cuff repair: Do not place the repaired tendon in a position that lengthens it further than the position obtained at operation for at least 6 weeks. Do not perform isometric contractions of the repaired tendon for 4 weeks. Do not perform resisted exercises throughout the range of the repaired tendon for up to 12 weeks. All movements should be relatively pain free.

Position for Lengthening muscles:

Position for Lengthening muscles Various position can help lengthen certain muscles, for example: Supraspinatus- adduction, horizontal adduction, hand behind back. Infraspinatus- adduction, horizontal adduction, hand behind back. Teres minor – elevation with internal rotation. Subscapularis – elevation, abduction in external rotation, abduction.

SAMPLE PROTOCOL FOR OPEN REPAIR OF FULL –THICKNESSROT CUFF TEAR:

SAMPLE PROTOCOL FOR OPEN REPAIR OF FULL –THICKNESSROT CUFF TEAR The post op protocol is divided into three phases- passive, active & strengthening exercises.

Day 1 Postoperatively:

Day 1 Postoperatively The patient’s arm is taken out of the sling, and the active elbow flexion/extension takes place with the upper arm held close to the trunk in a neutral position and the patient supine. With the patient supine & arm close to the side of the body, patient’s elbow may be flexed to 90 degree & passive ext rot commenced. Ideally, 45 degree of ext rot will be achieved within the first few days , but this will vary according to the surgeon’s closure technique. Passive forward flexion may also occur up to about 100 degree. The patient may perform rock-a-bye exercises. (Fig.8.12)

From Day 3 Postoperatively:

From Day 3 Postoperatively The patient may perform rock-a-bye or Pendular swinging exercises.

From Week 6 Postoperatively:

From Week 6 Postoperatively Active exercises, e.g. shoulder shrugging, elevation of the arm initially supported by the contralateral arm, or using a cane, may be commenced– these are usually easier if performed from a supine position. These exercises all emphasize regaining control of the shoulder. The emphasis should be on ensuring there is both good mobility and control of GH joint into elevation. The patient may progress to pulley exercises and wall climbing, i.e. taking the fingers up a vertical surface.

From Week 8 Postoperatively:

From Week 8 Postoperatively Resisted exercises Theraband or Elastic tubing or Cliniband exercises

From Week 12 Postoperatively:

From Week 12 Postoperatively Free weights, Bad Ragaz tech. Isotonic and Isokinetic exercises.

SAMPLE PROTOCOL FOR PARTIAL –THICKNESS ROT CUFF REPAIR WITH OPEN ACROMIOPLASTY:

SAMPLE PROTOCOL FOR PARTIAL –THICKNESS ROT CUFF REPAIR WITH OPEN ACROMIOPLASTY Day 1 Postoperatively Day 3 Postoperatively From week 3 Postoperatively From week 6 Postoperatively

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Pendulum, Circular - Bend forward 90 degrees at the waist, using a table for support. Rock body in a circular pattern to move arm clockwise 10 times, then counterclockwise 10 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Flexion (Assistive) - Clasp hands together and lift arms above head. Can be done lying down (drawing A) or sitting (drawing B). Keep elbows as straight as possible. Repeat 10 to 20 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Supported Shoulder Rotation - Keep elbow in place and shoulder blades down and together. Slide forearm back and forth. Repeat 10 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Walk Up Exercise (Active) - With elbow straight, use fingers to "crawl" up wall or door frame as far as possible. Hold 10 seconds. Repeat 3 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Internal Rotation (Active) - Bring hand behind back and across to opposite side. Repeat 10 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Flexion (Active) - Raise arm to point to ceiling, keeping elbows straight. Hold 10 seconds. Repeat 3 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Abduction (Active) - Raise arm out to side, elbow straight and palm downward. Do not shrug shoulder or tilt trunk. Hold 10 seconds. Repeat 3 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Extension (Isometric) - Stand with your back against the wall and your arms straight at your sides. Keeping your elbows straight, push your arms back into the wall. Hold for 5 seconds, then relax. Repeat 10 times.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder External Rotation (Isometric) - Stand with the involved side of your body against a wall. Bend your elbow 90 degrees. Push your arm into the wall. Hold for 5 seconds, then relax. Repeat 10 times.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Internal Rotation (Isometric) - Stand at a corner of a wall or in a door frame. Place the involved arm against the wall around the corner, bending your elbow 90 degrees. Push your arm into the wall. Hold for 5 seconds, then relax. Repeat 10 times.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Internal Rotation - Keep elbow bent at 90 degrees. Holding light weight, raise hand toward stomach. Slowly return. Repeat 10 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder External Rotation - Keep elbow bent at 90 degrees at side. Holding light weight, raise hand away from stomach. Slowly return. Repeat 10 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Adduction (Isometric) - Press upper arm against a small pillow alongside your body. Hold 5 seconds. Repeat 10 times. Do 3 sessions a day.

SHOULDER REHAB EXERCISES:

SHOULDER REHAB EXERCISES Shoulder Abduction (Isometric) - Resist upward motion to the side, push arm against back of chair. Hold 5 seconds. Repeat 10 times. Do 3 sessions a day.

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Post Surgical Management Phase I (first 6 weeks) Prevent atrophy, initiate protective motion, soft tissue healing and decrease pain Sling and immobilization Wrist and elbow exercises Active/active assisted ROM exercises Avoid extension and abduction Phase II (weeks 6-12) Restore full ROM, normalize arthrokinematics, improve stability and restore basic muscle strength ROM may require aggressive stretching to reach goals by week 8 Achieve full functional ROM (out of safe zone) Isotonic strengthening

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As full ROM is achieved continued strength development and work with arthro-kinematics and neuro-muscular control should be emphasized

Scapular Stabilization Exercises:

Scapular Stabilization Exercises

Neuromuscular Control:

Neuromuscular Control

Neuromuscular Control:

Neuromuscular Control

Advanced Strength Training:

Advanced Strength Training Pain free Full range of motion 70% of strength compared to uninvolved side High speed strengthening, plyometrics, PNF style training, isokinetics

Dynamic Stabilization:

Dynamic Stabilization

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Phase III Advanced activity strengthening Improve power, strength, endurance Enhance neuromuscular control and functional activities Flexibility and strengthening are progressed Single-hand plyometrics Interval sports specific program

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Phase IV – Return to activity Initiated from week 26-29 Involves gradual return to sports participation Full ROM, no pain, satisfactory strength measures (isokinetic) and normal clinical evaluation Full return is usually achieved by 7-10 months Criteria for Return to Play Same as described for other shoulder instability

Advanced Strength Training:

Advanced Strength Training Pain free Full range of motion 70% of strength compared to uninvolved side High speed strengthening, plyometrics, PNF style training, isokinetics

REHAB PROTOCOL Outline:

Phase 1 (0 to 6 weeks) Passive range of motion exercises only for almost all tears. Active-assisted range of motion for very small tears or repairs with exceptionally good tissue Phase 2 (6 to 12 weeks) Full passive motion Begin active-assisted motion Strengthen intact cuff muscles Begin to strengthen the muscles that stabilize the shoulder blade Phase 3 (12 to 16 weeks) Passive stretching beyond the patient's own range of motion Strengthening the repaired cuff muscles More strengthening of the stabilizers of the shoulder blade Phase 4 (> 16 weeks) Functional strengthening Rehabilitation for sports REHAB PROTOCOL Outline

REHABILITATION GUIDELINES FOR LARGE/MASSIVE ROTATOR CUFF TEARS FOLLOWING SURGICAL REPAIR:

REHABILITATION GUIDELINES FOR LARGE/MASSIVE ROTATOR CUFF TEARS FOLLOWING SURGICAL REPAIR

PHASE I: 0-6 weeks postoperatively:

PHASE I: 0-6 weeks postoperatively Goals Patient education Permit healing Control pain & inflammation Initiate ROM exercises

PHASE I: 0-6 weeks postoperatively:

PHASE I: 0-6 weeks postoperatively Immediate postoperative or postoperative day 1 Patients may be immobilized in sling or abduction brace if sling, use for comfort If abduction brace, immobilized for 3-6 weeks Pendulums Hand squeezes Elbow active ROM

PHASE I: 0-6 weeks postoperatively:

PHASE I: 0-6 weeks postoperatively 7-10 days postoperatively Pendulums Supine passive ROM forward elevation and ext rotation above level of brace Heat and ice Active scapular exercises (shoulder shrugs & scapular retraction)

PHASE II: 6-12 WEEKS POSTOPERATIVELY:

PHASE II: 6-12 WEEKS POSTOPERATIVELY GOALS Improve to full ROM Improve neuromuscular control & strength Treatment Continue all stretches Add phase II stretches ( internal rotation, cross body adduction, and extension) Rotator cuff isometrics (submaximal) Phase I strengthening (ext rotation, int rotation, extension) Resisted scapular strengthening (with arms below shoulder height)

PHASE III: 12-16 WEEKS POSTOPERATIVELY:

PHASE III: 12-16 WEEKS POSTOPERATIVELY Goals Full pain free ROM Optimize neuromuscular control Improve endurance Initiate return to functional activities Treatment Continue all stretches and strengthening Progress to phase II strengthening when at green for all phase I exercises (abduction, forward elevation, ext rotation at 45 degree in POS (plane of scapula) with arm supported) Manual resistance for rotator cuff and deltoid Bodyblade in no provocative positions

PHASE III: 16 WEEKS- 6 MONTHS POSTOPERATIVELY:

PHASE III: 16 WEEKS- 6 MONTHS POSTOPERATIVELY Goals Return to work, sport, or desired activities ( in appropriate patient) Promote concept of prevention Treatment Work hardening* Gradual return to work or desired activity Progress Bodyblade into elevated positions Work/sport specific exercises *applies to athlete or laborer

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