9/27 - Rotator Cuff Lesions & Post-Op Flashcards
what are influencing factors of how a postop RC tear will heal (6)
age
activity level
type of repair
tissue quality
size of tear
location of tear
what ab the tissue quality dictates how a postop RC heals
soft tissue integrity
- repair and surrounding tissue
osseous integiry
- fixation strength
what are the type of RC repair
open (delt taken down)
mini-open (delt split)
arthroscopic
what are the size categories of RC tears
small <1cm
medium 1-3cm
large 3-5cm
massive >5cm
what are size measurements of the RC tear really looking at and what do they tell you
looking at how much shoulder footprint has been disrupted
where do most RC tears start and how do they extend
start in supra
- extend either posteriorly or anteriorly
what are possible locations of the RC tear
isolated to supraspinatus
suprapinatus + infraspinatus
subscapularis
what demographics led to a positive outcome in postop RC tears (2)
younger age
male
what clinical factors led to a positive outcome in postop RC tears (5)
higher BMI
no DM
no obesity
inc pre-op ROM
inc sports activity
what about cuff integrity led to positive outcomes in post op RC tears (4)
smaller sagittal size
LESS RETRACTION
less fatty infiltrate
no multiple tendon involvement
what happens anatomically when there is a RC tear
retraction (under tension)
what role does time since injury play in success of a surgical intervention
longer it has been torn, tissue becomes scarred
- might never restore anatomic footprint
window for when you can get a successful repair
what surgical procedure factors led to positive outcomes in postop RC tears (2)
no concomitant biceps
no concomitant AC procedures
what had the most significant impact on a failed RC repair
fatty infiltration
- see retears
what had moderate impacts on a failed RC repair (3)
multiple tendon involvement
larger tear size
lower pre-op strength
what is an important consideration for RC repairs in older age
no impact on function
what is an arthroscopic acromioplasty used for?
impinging lesion
what does an arthroscopic acromioplasty do
acromial spur removed
coracoacromial ligament released
AC joint osteophytes excised
all this allows for more space in the subacromial region
what is an open repair done for
full thickness RC tears
pros of an open repair (2)
exposes all involved anatomy
allows for mobilization of tendons
cons of open repair (5)
release of delt
hospital stay
longer rehab
unable to examine GH joint/subacromial space
dec cosmesis
what do you see arthroscopically assisted mini-open repairs
full thickness RC tear
- usually w larger tears
pros of arthroscopically assisted mini-open repair (3)
visualization of cuff tear (open)
no deltoid release (arthroscopy)
possibly better fixation
what is the basics of what happens during a RC repair
take the delt away
restore anatomic footprint to where RC should be attached
suture to bone
what does a mini open repair create and what are the pros and cons to this
bleeding area - helps w healing
con - uncomfortable bc of how many nerve endings in bone
when is an arthroscopic RC repair done
full thickness RC tear
pros to an arthroscopic RC repair (4)
no delt release
limited morbidity
accelerated rehab
improved cosmesis
what is a con to arthroscopic RC repairs
technically demanding
what are rehab considerations after as surgical repair (2)
careful w activating ms early on
- only sutures holding it there
ms is gonna want to return to retracted position
what is an important consideration when looking at anatomic integrity
doesn’t correlate w functional outcomes or pt satisfaction
what does a more conservative approach mean for outcomes
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)
what was seen in early vs delayed ROM in post-op
no significant differences
what dictates how long until mobilization post-op
depends on surgeon
depends on tear and tissues
what risk accompanies early ROM
inc risk of re-tear
what is the general rule of thumb for post-op rehab
don’t add load until good ROM
don’t add resistance until good mobility
mobility before inc resistance for strength
4 PT exercises in phase 1 post op
protection & early motion
PROM flex - distal elbow, wrist
supine ER w dowel (PROM)
supine AAROM flex
forward bow (arm supported)
3 PT exercises in phase 2 post op
AA-AROM
AAROM flex»_space; AROM flex
ball roll (yoga ball on table)
supported wall slide (use foam roller)
3 PT exercises in phase 3 post op
strengthening
AROM flex
resisted ER, IR, ext, rows
forward punch
5 PT exercises in phase 4 post op
late strengthening
AROM flex/ABD
SL ER
standing ER @90deg
prone ER @90deg
prone H-ABD (Ts and Ys)
why are patients immobilized in ABD sling in first 6wks post op
prevents “wringing out”
dec tension on repair
why is PROM beneficial in phase 1
may assist w proper orientation of type 1 collagen
assist w proper tendon gliding
what should be avoided during PROM in phase 1
“stretching”
what are we trying to establish in phase 1
voluntary ms control
why should pendulums be prescribed w caution in early rehab
highly variable RC activation
performed incorrectly using shoulder vs body
what are interventions at phase 1 other than other therex (4)
pt ed
immediate PROM
manual scap strength
cryotherapy
what are qualities of immediate PROM in phase 1
@ elbow, wrist, and hand
- modify w biceps involvement
achieve stage ROM goals
in scap plane
caution w excessive ABD & IR
why is cryotherapy utilized in phase 1
control post-op pain
dec swelling & ms spasm
what dictates the stage the pt is in
milestones not time
what milestones must be achieved to progress from phase 1 to 2
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
what are interventions in phase 2 (10)
dc sling (consider pain & compliance)
progress to full PROM
initiate self-assisted AAROM»_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
where is stability focused in phase 2
scapulothoracic
what strengthening interventions can be implemented at the end of phase 2 (3)
isometrics
scaption w ER (full can)
SL ABD to 45deg
- inc supraspinatus w dec risk of impingement
what is important to be aware of w interventions in phase 2
don’t want to recreate shoulder pain
- avoid painful exercises
what are milestones to progress from phase 2 to 3 (3)
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
phase 3 interventions/goals (7)
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
guidelines for phase 3 interventions (3)
in scapular plane initially
no compensatory patterns
high rep focus
milestones to progress from phase 3 to 4 (2)
adequate strength and dynamic stability for progression to work / sport activity
normal scapular position
- static and dynamic
what are 3 interventions in phase 4
replicate demands of ADL and work activity
plyometric program
initiate interval sport program
what is the surgery of choice in younger populations for massive RC tears? where is RC tear for this to be a viable option?
lat dorsi transfer
- posterosuperior tears
why do a lot of RC tears develop into massive RC tears
atrophy
fatty infiltrate
who is a good candidate for a non-op management of an irreparable massive RC tear? what is a con of this management?
low demand pts
OA over time
pros and cons of partial repair and debridement of an irreparable massive RC tear
pros - good results
cons - limited long-term data
who is a good candidate for a reverse TSA of an irreparable massive RC tear
elderly pts w advanced OA
who is a good candidate for a lat dorsi transfer for an irreparable massive RC tear? what is a con of this management?
younger pts w posterosuperior tears
high complication rates
what are 2 techniques for superior capsule reconstruction
fascia lata autograft
dermal allograft
what is needed for a superior capsule reconstruction to be successful
functioning delt and subscap
what is the point of a superior capsule reconstruction
prevents superior migration
what are treatment options for irreparable massive RC tears (5)
non op
partial repair and debridement
reverse TSA
lat dorsi transfer
superior capsule reconstruction
goals for phase 1 after a superior capsule reconstruction for a massive RC tear (4)
maximal protection
protect repair
min pain/inflammation
maintain mobility accessory joints
pt ed
interventions for phase 1 after a superior capsule reconstruction for a massive RC tear (6)
immobilized in ABD sling x6wks
cryotherapy
AROM cervical spine
AROM elbow, wrist, hand out of sling
ball squeezes
scap retraction/depression
goals for phase 2 after a superior capsule reconstruction for a massive RC tear (5)
ROM and endurance
restore ROM
inc RC endurance
restore SH rhythm
initiate LIGHT ADLSs
wean sling
interventions for phase 2 after a superior capsule reconstruction for a massive RC tear (4)
PROM / AROM to tolerance
- ex: SL ABD, SL H-ABD
delt activation
ER function (dependent on tissue quality)
scap and GH isometrics
goals for phase 3 after a superior capsule reconstruction for a massive RC tear (3)
strength
advanced strength
restore functional ROM
resume higher level functional activities
interventions for phase 3 after a superior capsule reconstruction for a massive RC tear (3)
progressive resisted ROM
initiate CKC exercises
** normal SH rhythm**
goal for phase 4 after a superior capsule reconstruction for a massive RC tear
advanced strength and return to activity
- as appropriate on pt case basis
interventions for phase 4 after a superior capsule reconstruction for a massive RC tear (4)
ENDURANCE
overhead strength
advanced CKC
plyometrics
what are the 7 keys to success to rehab
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
