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MSK 1 > 9/27 - Rotator Cuff Lesions & Post-Op > Flashcards

9/27 - Rotator Cuff Lesions & Post-Op Flashcards

1
Q

what are influencing factors of how a postop RC tear will heal (6)

A

age
activity level
type of repair
tissue quality
size of tear
location of tear

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2
Q

what ab the tissue quality dictates how a postop RC heals

A

soft tissue integrity
- repair and surrounding tissue
osseous integiry
- fixation strength

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3
Q

what are the type of RC repair

A

open (delt taken down)
mini-open (delt split)
arthroscopic

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4
Q

what are the size categories of RC tears

A

small <1cm
medium 1-3cm
large 3-5cm
massive >5cm

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5
Q

what are size measurements of the RC tear really looking at and what do they tell you

A

looking at how much shoulder footprint has been disrupted

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6
Q

where do most RC tears start and how do they extend

A

start in supra
- extend either posteriorly or anteriorly

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7
Q

what are possible locations of the RC tear

A

isolated to supraspinatus
suprapinatus + infraspinatus
subscapularis

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8
Q

what demographics led to a positive outcome in postop RC tears (2)

A

younger age
male

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9
Q

what clinical factors led to a positive outcome in postop RC tears (5)

A

higher BMI
no DM
no obesity
inc pre-op ROM
inc sports activity

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10
Q

what about cuff integrity led to positive outcomes in post op RC tears (4)

A

smaller sagittal size
LESS RETRACTION
less fatty infiltrate
no multiple tendon involvement

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11
Q

what happens anatomically when there is a RC tear

A

retraction (under tension)

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12
Q

what role does time since injury play in success of a surgical intervention

A

longer it has been torn, tissue becomes scarred
- might never restore anatomic footprint

window for when you can get a successful repair

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13
Q

what surgical procedure factors led to positive outcomes in postop RC tears (2)

A

no concomitant biceps
no concomitant AC procedures

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14
Q

what had the most significant impact on a failed RC repair

A

fatty infiltration
- see retears

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15
Q

what had moderate impacts on a failed RC repair (3)

A

multiple tendon involvement
larger tear size
lower pre-op strength

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16
Q

what is an important consideration for RC repairs in older age

A

no impact on function

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17
Q

what is an arthroscopic acromioplasty used for?

A

impinging lesion

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18
Q

what does an arthroscopic acromioplasty do

A

acromial spur removed
coracoacromial ligament released
AC joint osteophytes excised

all this allows for more space in the subacromial region

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19
Q

what is an open repair done for

A

full thickness RC tears

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20
Q

pros of an open repair (2)

A

exposes all involved anatomy
allows for mobilization of tendons

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21
Q

cons of open repair (5)

A

release of delt
hospital stay
longer rehab
unable to examine GH joint/subacromial space
dec cosmesis

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22
Q

what do you see arthroscopically assisted mini-open repairs

A

full thickness RC tear
- usually w larger tears

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23
Q

pros of arthroscopically assisted mini-open repair (3)

A

visualization of cuff tear (open)
no deltoid release (arthroscopy)
possibly better fixation

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24
Q

what is the basics of what happens during a RC repair

A

take the delt away
restore anatomic footprint to where RC should be attached
suture to bone

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25
Q

what does a mini open repair create and what are the pros and cons to this

A

bleeding area - helps w healing

con - uncomfortable bc of how many nerve endings in bone

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26
Q

when is an arthroscopic RC repair done

A

full thickness RC tear

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27
Q

pros to an arthroscopic RC repair (4)

A

no delt release
limited morbidity
accelerated rehab
improved cosmesis

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28
Q

what is a con to arthroscopic RC repairs

A

technically demanding

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29
Q

what are rehab considerations after as surgical repair (2)

A

careful w activating ms early on
- only sutures holding it there

ms is gonna want to return to retracted position

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30
Q

what is an important consideration when looking at anatomic integrity

A

doesn’t correlate w functional outcomes or pt satisfaction

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31
Q

what does a more conservative approach mean for outcomes

A

healing might be better
*may improve rate of tendon healing (less re-tears)

see some early stiffness but usually regain mobility
*no long term stiffness (1yr)

32
Q

what was seen in early vs delayed ROM in post-op

A

no significant differences

33
Q

what dictates how long until mobilization post-op

A

depends on surgeon
depends on tear and tissues

34
Q

what risk accompanies early ROM

A

inc risk of re-tear

35
Q

what is the general rule of thumb for post-op rehab

A

don’t add load until good ROM
don’t add resistance until good mobility
mobility before inc resistance for strength

36
Q

4 PT exercises in phase 1 post op

A

protection & early motion

PROM flex - distal elbow, wrist
supine ER w dowel (PROM)
supine AAROM flex
forward bow (arm supported)

37
Q

3 PT exercises in phase 2 post op

A

AA-AROM

AAROM flex&raquo_space; AROM flex
ball roll (yoga ball on table)
supported wall slide (use foam roller)

38
Q

3 PT exercises in phase 3 post op

A

strengthening

AROM flex
resisted ER, IR, ext, rows
forward punch

39
Q

5 PT exercises in phase 4 post op

A

late strengthening

AROM flex/ABD
SL ER
standing ER @90deg
prone ER @90deg
prone H-ABD (Ts and Ys)

40
Q

why are patients immobilized in ABD sling in first 6wks post op

A

prevents “wringing out”
dec tension on repair

41
Q

why is PROM beneficial in phase 1

A

may assist w proper orientation of type 1 collagen

assist w proper tendon gliding

42
Q

what should be avoided during PROM in phase 1

A

“stretching”

43
Q

what are we trying to establish in phase 1

A

voluntary ms control

44
Q

why should pendulums be prescribed w caution in early rehab

A

highly variable RC activation
performed incorrectly using shoulder vs body

45
Q

what are interventions at phase 1 other than other therex (4)

A

pt ed
immediate PROM
manual scap strength
cryotherapy

46
Q

what are qualities of immediate PROM in phase 1

A

@ elbow, wrist, and hand
- modify w biceps involvement

achieve stage ROM goals
in scap plane

caution w excessive ABD & IR

47
Q

why is cryotherapy utilized in phase 1

A

control post-op pain
dec swelling & ms spasm

48
Q

what dictates the stage the pt is in

A

milestones not time

49
Q

what milestones must be achieved to progress from phase 1 to 2

A

appropriate healing
- compliant w immobilization
- compliant w precautions

staged ROM goals on target
- scaption (90-120)
- ER @20deg ABD (20-45)
- ER @45deg ABD (40-60)

minimal pain w ROM
- ~2/10

50
Q

what are interventions in phase 2 (10)

A

dc sling (consider pain & compliance)
progress to full PROM
initiate self-assisted AAROM&raquo_space; AROM
strengthening (no resisted RC)
dynamic stability of ST
independent w ADLs (by end of phase)
cont pec minor P-AA - AROM
cont rhythmic stabilization scap PNF
- middle and lower traps
strength
low level functional activities

51
Q

where is stability focused in phase 2

A

scapulothoracic

52
Q

what strengthening interventions can be implemented at the end of phase 2 (3)

A

isometrics
scaption w ER (full can)
SL ABD to 45deg
- inc supraspinatus w dec risk of impingement

53
Q

what is important to be aware of w interventions in phase 2

A

don’t want to recreate shoulder pain
- avoid painful exercises

54
Q

what are milestones to progress from phase 2 to 3 (3)

A

staged AROM achieved
- 0-2/10 pain
- without compensation

strengthening activities progressing
- 0-2/10 pain

normal scapular position
- static and dynamic
- normal upward rotation

55
Q

phase 3 interventions/goals (7)

A

full P/AROM
dynamic shoulder stability
shoulder strength & endurance
CKC activities
neuro re-ed (ie joint reposition - IR/ER)
return to work activities
initiate modified rec activities

56
Q

guidelines for phase 3 interventions (3)

A

in scapular plane initially
no compensatory patterns
high rep focus

57
Q

milestones to progress from phase 3 to 4 (2)

A

adequate strength and dynamic stability for progression to work / sport activity

normal scapular position
- static and dynamic

58
Q

what are 3 interventions in phase 4

A

replicate demands of ADL and work activity
plyometric program
initiate interval sport program

59
Q

what is the surgery of choice in younger populations for massive RC tears? where is RC tear for this to be a viable option?

A

lat dorsi transfer
- posterosuperior tears

60
Q

why do a lot of RC tears develop into massive RC tears

A

atrophy
fatty infiltrate

61
Q

who is a good candidate for a non-op management of an irreparable massive RC tear? what is a con of this management?

A

low demand pts
OA over time

62
Q

pros and cons of partial repair and debridement of an irreparable massive RC tear

A

pros - good results
cons - limited long-term data

63
Q

who is a good candidate for a reverse TSA of an irreparable massive RC tear

A

elderly pts w advanced OA

64
Q

who is a good candidate for a lat dorsi transfer for an irreparable massive RC tear? what is a con of this management?

A

younger pts w posterosuperior tears
high complication rates

65
Q

what are 2 techniques for superior capsule reconstruction

A

fascia lata autograft
dermal allograft

66
Q

what is needed for a superior capsule reconstruction to be successful

A

functioning delt and subscap

67
Q

what is the point of a superior capsule reconstruction

A

prevents superior migration

68
Q

what are treatment options for irreparable massive RC tears (5)

A

non op
partial repair and debridement
reverse TSA
lat dorsi transfer
superior capsule reconstruction

69
Q

goals for phase 1 after a superior capsule reconstruction for a massive RC tear (4)

A

maximal protection

protect repair
min pain/inflammation
maintain mobility accessory joints
pt ed

70
Q

interventions for phase 1 after a superior capsule reconstruction for a massive RC tear (6)

A

immobilized in ABD sling x6wks
cryotherapy
AROM cervical spine
AROM elbow, wrist, hand out of sling
ball squeezes
scap retraction/depression

71
Q

goals for phase 2 after a superior capsule reconstruction for a massive RC tear (5)

A

ROM and endurance

restore ROM
inc RC endurance
restore SH rhythm
initiate LIGHT ADLSs
wean sling

72
Q

interventions for phase 2 after a superior capsule reconstruction for a massive RC tear (4)

A

PROM / AROM to tolerance
- ex: SL ABD, SL H-ABD
delt activation
ER function (dependent on tissue quality)
scap and GH isometrics

73
Q

goals for phase 3 after a superior capsule reconstruction for a massive RC tear (3)

A

strength

advanced strength
restore functional ROM
resume higher level functional activities

74
Q

interventions for phase 3 after a superior capsule reconstruction for a massive RC tear (3)

A

progressive resisted ROM
initiate CKC exercises
** normal SH rhythm**

75
Q

goal for phase 4 after a superior capsule reconstruction for a massive RC tear

A

advanced strength and return to activity
- as appropriate on pt case basis

76
Q

interventions for phase 4 after a superior capsule reconstruction for a massive RC tear (4)

A

ENDURANCE
overhead strength
advanced CKC
plyometrics

77
Q

what are the 7 keys to success to rehab

A

establish PROM
restore ER strength
establish shoulder balance
improve scap position & movement
gradually inc loads
avoid aggressive activities early on
gradual return to functional activities

MSK 1 (31 decks)

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