Shoulder Surgery & Rehab Flashcards
What are the common types of shoulder surgery?
- Fracture repair (open reduction internal fixation ORIF)
- Rotator cuff reconstruction
- Shoulder arthroplasty
- Stabilisation (anterior capsule reconstruction)
- Superior Labral Anterior Posterior Repair (SLAP)
- Acromioplasty
What is involved in a post-operative examination of a shoulder?
- AROM of cervical spine/thoracic spine, elbow, wrist and fingers
- If allowed, PROM of shoulder assessed in supine
- Girth measurements at the elbow/wrist
What is involved in post-op stage 1 shoulder rehab?
- Treatment & exercise
- Mobility
- Comfort - sling
- Hygiene
- Dressing
- Education (safety, future progression)
- Other joint health
- Discharge planning
What are the common early active rehab strategies?
- Sling management
- Scapula setting
- Neck, wrist, elbow AROM
- +/- glenohumeral isometrics
What are common early passive rehab exercises?
- Pendulum exercise: ROM without active contraction of shoulder joint muscles
- Hand on bed, abduction, adduction, flexion, external/internal rotation
How is a proximal humeral fracture classified?
- 4 parts of proximal humerus: greater/lesser tuberosities, humeral head, humeral shaft
- By number of parts displaced
- By displacement >1cm from humerus
- By angulation of part >45 degrees
What are some of the considerations for early rehab of shoulder fractures?
- Quality of hard/soft tissues
- Degree of commutation
- Difficulty/quality of repair
- Stability of repair
- Surgeon’s orders
What are the indications for shoulder arthroplasty (replacement)?
- Severe arthritis
- Rotator cuff failure (& OA)
- Un-reconstructable fracture
What are the types of shoulder arthroplasties?
- Total
- Hemi (half)
- Resurfacing hemi +/- glenoid
- Cuff tear arthroplasty (CTA) head hemi
- Reverse total
Why is a beach chair position often used for a shoulder arthroplasty?
- Adequate exposure of humeral head/glenoid
- Ensures arm can be positioned correctly
What is the standard incision for shoulder arthroplasty?
Deltopectoral approach
- Lateral to coracoid process, extends down proximal arm
- Deltopectoral interval exposed from leading edge of clavicle to lower end of pec
- Subscapularis may be detached
What are the common restrictions for a standard TSA?
- Passive ROM for up to 6/52
- Abduction pillow for up to 8/52
- ER limited to 30 degrees with humerus at 0 degrees of adduction
What are the restrictions for a reverse TSA?
- Inherently unstable 0-12 weeks
- No combined adduction/IR/ER
- No extension beyond neutral
What are the considerations for shoulder arthroplasty rehab?
- Preop history/impairments
- Surgical technique
- Prosthetic type
- Surgeon’s assessment of tissue status
What is the focus for the first 6 weeks of TSA rehab?
- Protection of the healing structures
- Progression of ROM for prevention of muscular contraction & joint stiffness
What are some of the lesions associated with traumatic anterior instability?
- Bankart lesion: Avulsion of anteroinferior glenoid labrum at attachment to IGHL complex
- Hill-Sach’s lesion: Posterolateral humeral head indentation fracture from anterior shoulder dislocation
- Rotator interval incompetence & capsular laxity
What is the rotator interval?
Capsule between supraspinatus and subscapularis
What are the 3 portals of shoulder stabilisation?
- Posterior: 1.5-3cm distal/1-2cm medial to posterolateral tip of acromion in interval between infraspinatus and trees minor
- Anterior superior: Anterior to biceps tendon
- Anterior inferior: Above superior edge of subscapularis
What does surgery for stabilisation of anterior/inferior shoulder ligaments involve?
- Anterior glenoid rasped and decorticated in preparation
- Anchors placed on edge of articular surface in 7/9/11 o’clock positions
- Suture is passed through the tissue, reattaching ligaments to glenoid
- Repair is evaluated for stable fixation
What are the 2-4 week goals post anterior shoulder stabilisation?
- Progress from PROM to AAROM to AROM while protecting anterior joint capsule
- Progress scapular stabilisation exercises
- Inhibit rotator cuff exercises
What are the 4-8 week goals post anterior shoulder stabilisation?
- Full ROM expected by 8 weeks
- Progress dynamic scapular stabilisation and rotator cuff strengthening exercises
- Return to ADLs and functional activities that don’t stress the anterior capsule
What are some of the pathologies associated with rotator cuff injuries?
- Traumatic
- Degenerative
- Congenital abnormalities
- Scapulothoracic dysfunction
- Glenohumeral instability
- Degenerative changes (tears)
What are the indications for surgery for rotator cuff?
- Faulure of 3-6 months of conservative care
- Acute full thickness tear in an active patient younger than 50
What types of surgeries are used for rotator cuff injuries?
- Arthroscopic: Impingement
- Arthroscopic/mini open:
Partial thickness cuff tears - Open: Full thickness cuff tears
What occurs in an open rotator cuff surgery?
- Trough is created in proximal humerus lateral to articular surface
- Sutures tied over the bone bridge in the greater tuberosity
What are the 1-4 week goals post rotator cuff repair?
- Protect, support, maintain
- Increase ROM as tolerated
- Scapular isometrics
- Avoid AROM abduction/ER and PROM horizontal adduction, extension IR
- Avoid leaning on elbow, sleeping on side, sudden movements, pushing/pulling/lifting
What are the 5-8 week goals post rotator cuff repair?
- Support, protect, maintain
- Increase ROM and active strength
- Avoid positions that compromise repaired tissues (horiztonal adduction, IR beyond 70 deg, extension)`
What are the 8-13 week goals post rotator cuff repair?
- Increase ROM
- Avoid impingement problems
- Gain near full ROM
- Increase strength/function
What are the 3 post-surgical phases for acromioplasty rehab?
- Phase 1 (2-3 weeks): Support, protect, maintain, minimise effects of immobilisation
- Phase 2 (3-6 weeks): Muscle strengthening, continued work on rotator cuff & scapular stabilising strengthening
- Phase 3 (9-12 weeks): Enhancing kinaesthesia/joint position sense, building endurance, strengthening scapular stabilising, work-/sport-specific tasks
