Shoulder Flashcards
TSA
total shoulder arthroplasty
RTSA
reverse total shoudler arthroplasty
RCR
rotator cuff repair
What is replaced in a TSA?
glenoid and humeral surfaces
RCTR
rotator cuff total repair
Unconstrained
- rotator cuff must be intact
- small, shallow glenoid component
- allows greatest freedom of motion, not inherent stability
Semiconstrainsted
- larger glenoid component
- some degree of stability provided
- rotator cuff may be mildly deficient prior to repair
Reverse ball and socket
Small humeral socket that slides on a larger ball shaped glenoid component
Provides some stability with mobility for rotator cuff deficient shoulders that cannot be repaired
Constrained
Greatest amount of stability
Fixed fulcrum, ball in socket designs
Rarely used to due high rate of loosening and failure of components
TSA vs Hemiarthroplasty…may be accompanied by:
- Rotator cuff repair
- Subscapularis reattachment and lengthening if a contracture is present that significantly limits external rotation
- Capsular tightening for chronic subluxation/dislocation (usually posterior) of GH joint
- Anterior acromioplasty (if hx of impingement syndrome)
- Bone graft of the glenoid
Postoperative complications of shoulder replacement
Pulmonary embolism, DVT
Infection
Postoperative complications during acute phase of care
Axillary and/or suprascapular nerve damage. . . . Dislocation Fracture Re-tearing a repaired rotator cuff -suturing was insufficient -ROM was too aggressive
Positioning
Sling for comfort; abduction splint for stability
Elbow flexed to 90; shoulder flexed 10-20 with slight abduction and IR
HOB at 30 degrees
Precautions
Absolutely NO end-range stretching; esp. to subscapularis NO AROM in antigravity position NO dynamic shoulder exercises NO resistance exercises NO weight bearing on operative UE NO lifting NO reaching behind the back
Interventions
Mobility of adjacent joints and of whole person!
Patient education of precautions
Splint use/positioning/protection of implant and healing tissues
Postural Rehab!!!!!
Shoulder mobility during maximum protective phase
PROM in allowable range; attempt in supine Pendulum exercises (Codman’s) Scapular stabilization exercises in NWB position
At end of maximum protective phase
Self-assisted ROM (Other hand, wand, resting on table)
If rotator cuff was repaired during TSA, how long until AROM and light isometrics?
6 weeks
Rehab: hospital to home
Passive external rotation to neutral or to less than 30 degrees
- avoid stress to the anterior capsule
- teach scapular stabilization exercises on the non surgical shoulder; instruct patient to begin these at approx. 4 to 6 weeks post/op
Criteria to advance to Moderate Protection/controlled motion phase 6-12 weeks
90 degrees passive elevation
45 degrees of ER
70 degrees of IR in the plane of the scapula with minimum pain; or full, PROM with little to no pain
NO subscapularis tendon pain with resisted, isometric IR
Progressing TSA Weeks 12-16 Criteria to progress to Minimum Protection/Return to Functional Activity ;
Full, PROM of the GHJ (based on intraoperative ranges). . .or at least 130-140 degress PROM or AAROM shoulder flexion and 120 degrees of abduction
60 degrees pain free, PROM ER and 70 degrees IR in the plane of the scapula
AROM 100-120 degrees in the plane of the scapula with proper joint stability: NO OVERFIRING OF . . .TRAPS
Strength of rotator cuff and deltoid muscles 4/5
Reverse TSA rehab protocol
Avoidance of shoulder extension past neutral and the combination of shoulder adduction and internal rotation should be avoided for 12
weeks postoperatively.
Reverse TSA patients typically dislocate with the arm
in internal rotation and adduction in conjunction with extension.
Rotator cuff repair performed when:
Are symptomatic and have functional limitations after a trial of nonoperative treatment (Neer classification stage II and stage III lesions).
Have acute, traumatic rupture of rotator cuff tendons, often combined with other GH joint trauma.
Subacromial decompression; deltoid splitting; deltoid detachment then repair
Most commonly torn cuff tendon:
supraspinatus
Common elements of rotator cuff repair:
Immediate or early post-op GH joint movement*
Control of the rotator cuff for dynamic stability
Gradual restoration of strength and muscular endurance
How long is rotator cuff repair–maximum protection phase?
3-8 weeks post-op depending if surgery was for small or medium repair vs. large to massive repair
When is the moderate protection phase of a rotator cuff repair?
begins 6 to 12 weeks post op
6 weeks for small tear repair
Criteria for moderate protection phase of rotator cuff:
Well healed incision
Minimal pain with AAROM of shoulder
Progressive improvement in ROM
Minimum Protection/Return to Function Phase for Rotator Cuff Repair
usually begins 12 to 16 weeks post-op
Criteria for Minimum Protection/Return to Function Phase for Rotator Cuff Repair
Full, pain-free PROM
Progressive improvement of shoulder strength and muscular endurance
Stable GH joint
Common sources of referred pain in the shoulder region
C3-C4
C4-C5
Nerve root C4
Nerve root C5
Referred pain from related tissues
C4 dermatome C5 dermatome Diaphragm Heart Gallbladder irritation
Nerve disorders in the shoulder girdle region
Brachial plexus in the thoracic outlet
Suprascapular nerve in the suprascapular notch
Radial nerve in the axilla
Possible nonoperative causes of GH joint hypomobility
Rheumatoid arthritis and osteoarthritis
Traumatic arthritis
Post immobilization arthritis or stiff shoulder
Idiopathic frozen shoulder (adhesive capsulitis)
Three phases of frozen shoudler
- Freezing:
- Frozen
- Thawing
Freezing shoulder:
intense pain, even at rest, and limitation of motion by 2-3 weeks after onset
may last 10-36 weeks
Frozen shoulder
pain only with movement, significant adhesions, limited GH motions, substitute motions in scapula
Atrophy of deltoid, rotator cuff, bicep and triceps occurs
may last 4-12 months
Thawing shoulder
No pain and no synovitis, but significant capsular restrictions from adhesions
may last 2-24 months, some patients never regain normal ROM
GH treatment option goals
-control pain, edema, and joint effusion
GH treatment options
PROM Passive joint mobilization techniques Pendulum exercises Self-mobilization techniques Manual stretching Self-stretching exercises Ensure correct mechanics with shoulder movements
Nonoperative causes of AC and SC joint hypomobility
Overuse syndromes
Subluxations or dislocations
Sustained faulty postures
Painful shoulder syndromes
-tendinitis/bursitis
-shoulder instability/subluxation
Impaired posture
Muscle imbalance
Decreased thoracic ROM
Rotator cuff overuse or fatigue
Primary mover in a RTSA
deltoid muscle becomes primary mover of GH joint
Primary mover in a TSA?
functioning rotator cuff muscles move GH joint
