Surgical Treatment of Shoulder Pathologies Flashcards
What is the test-item cluster for a full thickness rotator cuff tear?
- Drop arm sign ( + w/ pain or arm drops)
- Painful Arc (+ is pain or catching between 60-120 deg.)
- Infraspinatus muscle test (+ with pain, weakness, or lag)
If all three positive and patient;s age is over 60 it has a very high likelihood ratio
What would be considered a small full thickness rotator cuff tear?
Medium tear?
Large?
under 1 cm
1-3 cm
3-5 cm
anything over 5 cm is massive
What is the difference between a 1A and a 1B rotator cuff tear?
1A is a horizontal tear
1B is a longitudinal tear
What are the treatment options for a rotator cuff tear?
- Non-operative management (depends on status of remaining RC)
- Decompression w/o repair
- Repair
What does phase 1 of post-operative management for subacromial decompression look like as far as time, ROM, modalities, suggested exercises and goals?
Time: 0-2 weeks
ROM: no lifting overhead but can do all A/PROM as symptoms indicate
Modalities: cryotherapy 3-5x per day, if pain is present then IFC is appropriate
Suggested Exercise: pendulums, cane exercises within pain free ROM, isometrics, rhythmic stabilization, grade 1-2 MTT
Goals:
- decrease pain and inflammation
- Return ROM
- Minimize strength loss
What does phase 2 of post-operative management for subacromial decompression look like as far as time, ROM, modalities, suggested exercises and goals?
Time: 3-6 weeks
ROM: symptoms should be resolving and we should be progressing toward full ROM at the end of 6 wks
Modalities: cryotherapy post rx and IFC is appropriate if pt. complains of pain
Suggest Exercises: Unweighted GH exercises, IR/ER in scaption, sidelying ER, prone ER with horiz. abd, lower and mid trap training
Goals:
- improve strength
- normalize scapulohumeral rhythm
- resolution of pain
What does phase 3 of post-operative management for subacromial decompression look like as far as time, ROM, modalities, suggested exercises and goals?
Time: 7-12 wks
ROM: full ROM should be achieved by this point
Modalities: cryotherapy or hot pack PRN
Suggested Exercise: scap staibs, OKC/CKC total arm ex’s, scap staibs, perturbation training, plyos
Goals:
- return of static strength and endurance
- Normal scapular motion
- Return to sport
What does post-op management of rotator cuff repair depend on?
- surgical approach
- size and location of tear
- quality of soft tissue and bone
- quality of fixation
communication w/ surgeon is critical-request copy of surgical report
What is the most common surgical technique for small/medium RC tears?
What does post-operative management look like for these patients?
Arthroscopic or deltoid splitting approach
- primary goal is to protect the repair
- sling for 4 weeks
- emphasis on PROM for 4 weeks except ER
- No AROM or resistance
- Ice and stim for pain control
- Grade 1/2 mobs for pain relief
- AAROM in supine can be added week 3
- AAROM in sitting/standing can be added week 4
- progress to active exercise after 6 weeks
- light resisted exercises for RC may be initiated after 8 wks if active motion is satisfactory
What is the most common surgical technique for large/massive RC tears?
What does post-operative management look like for these patients?
Open with deltoid detachment
- primary goal is to reduce pain and protect repair
- PROM within limits imposed by surgeon after 1-2 wks
- sling for 6-8 wks
- emphasis on PROM for 4 wks
- No elevation for 608 wks due to deltoid damage
- continue passive motion for 3-4 wks
- AAROM can begin 4-6 wks, avoid elevation and ER
- active motion after 6-8 wks
- full ROM should be achieved between 12-16 wks
What are the indications for shoulder arthroplasty?
- degenerative joint disease such as OA, RA, Post-traumatic RA, or proximal humeral fractures
- rotator cuff tear arthroplasty
- AVN
- past failed replacement
What is the goal of shoulder arthroplasty?
restore function, decrease, pain and improve sleep quality
What are the general rehab guidelines for total shoulder arthroplasty?
What phases can rehab be divided into?
- sling during the day for 1-2 wks and at night for 4-6 wks
- patient education
- general ROM for the first 4-6 wks
- add strength at 4 wks progressing to isometrics in different positions
- respect pain and muscle guarding through entire rehab
- return to sports and recreational activities after 4-5 months
Phase 1- no forced motion, no IR past frontal
Phase 2- no lifting over 2-3 lbs.
Phase 3-4
What are the goals for phase 1 of total shoulder arthroplasty rehab?
What are the recommended exercises for this phase?
- reduce pain and inflammation
- maintain integrity of arthrosis
- reduce muscular inhibition
- Increase PROM, initiate AAROM late in phase
- Full distal extremity (elbow, wrist, hand) AROM
- Independence w/ modified ADL’s
exercise:
- cryotherapy to manage pain and inflammation
- scapular isometrics
- PROM as motion allows
- Avoid stress on the anterior capsule, particularly shoulder in extension
- AROM of distal extremity- strengthening as appropriate
What are the goals for phase 2 of total shoulder arthroplasty rehab?
What are the recommended exercises for this phase?
- control pain and inflammation and continued healing of soft tissue
- full PROM
- increase AROM
- Do not overstress healing tissue
- Initiate dynamic shoulder stability
exercise:
- cryotherapy
- continue AAROM/PROM exercises
- manual therapy
- initiate AROM
- begin submax shoulder isometrics
- initiate stabilization exercises
- continue distal strengthening
What are the goals for phase 3 of total shoulder arthroplasty rehab?
What are the recommended exercises for this phase?
- Gradual restoration of shoulder strength, power, and endurance
- Optimize nueromuscular control
- Gradual return to functional activities w/ involved UE
Exercises:
- progress PROM/AROM activities
- manual therapy
- initiate assisted shoulder IR behind back stretch
- resisted IR/ER in scapular plane
- begin functional activities
- initiate active elevation w/ light weights
What are the goals for phase 4 of total shoulder arthroplasty rehab?
What are the recommended exercises for this phase?
- Non-painful AROM
- Functional use of UE
- Maximize strength and endurance
- Gradual return to more advanced functional activities
Exercises:
- AROM in all planes
- resistive exercises in pain free range
- perturbation training
- functional activities
What is the criterion to progress from phase 1 of shoulder arthroplasty rehab into phase 2?
- Achieve at least 90 deg PROM flexion and abduction
- Achieves at least 45 deg. PROM ER in scapular plane
- Achieves at least 70 deg. PROM IR in scapular plane @ 30 deg. of abduction
What is the criterion to progress from phase 2 of shoulder arthroplasty rehab into phase 3?
- tolerates PROM/AAROM
- PROM: 140 deg flexion; 120 deg abduction; 60 deg. ER in scapular plane 70 deg. PROM IR in plane of scapula measured at 30 deg of abduction
- Able to actively elevate shoulder against gravity w/ good mechanics to 100 deg
What is the criterion to progress from phase 3 of shoulder arthroplasty rehab into phase 4?
- tolerates AAROM/AROM/strengthening
- AROM: 140* flexion 120* abduction in supine 60* AROM ER in plane of scapula supine; 70* AROM IR in plane of scapula supine in 30* of abduction
- 120* active elevation against gravity w/o substitution
What is the criterion to progress from phase 4 of shoulder arthroplasty rehab to discharge?
- Independent w/ HEP
- 80% UE AROM non-painful
- Full functional use of UE
- Maximized muscular strength, power, and endurance
- patient has returned to advanced functional activities
What is a reverse total shoulder arthroplasty?
What injury calls for this surgery technique?
What are the anticipated outcomes for this surgery?
Surgery where shoulder is replaced in an opposite alignment than anatomical original where the shoulder becomes the ball and the humerus becomes the socket
Complete RC tear or massive RC tear or if there has been AC degeneration/erosion of the CA ligament
Reversal of biomechanics
- increased moment arm of the deltoid
- increased overhead elevation
- decreased pain
What post-op considerations are there for reverse TSA surgeries?
Joint protection:
- typically will not dislocate in ER and abduction
- limits will be in IR/add in conjunction w/ extension
- usual precautions for 12 wks
Deltoid function:
- changes in shoulder stability to rely more on deltoid
- scapular stabilizers
- movement dysfunction (biofeedback)
Establishment of appropriate functional and ROM expectations
- Er dependent on condition of the TM
- Case dependent (those w/ (-) ER lag sign tend to progress quicker in terms of strength)
What are the goals and precautions for phase 1 of rTSA rehab?
Goals:
- maintain integrity of joint
- restore PROM
- patient/family education
Precautions:
- delay PROM for 3-6 wks
- Usually begin w/ PROM around weeks 4 allow deltoid tissue to heal
- if approach other than traditional deltopectoral approach used
What are the exercises guidelines for rTSA rehab post-op and in phase 1?
Post-op:
- immobilization w/ abduction sling
- AROM to distal extremity
- protect prosthesis and soft tissue
- PROM limits: flexion/elevation to 90 and ER to 20-30 (no IR for first 6 wks)
- submax isos to deltoid and periscapular musculature
Phase 1:
- cryotherapy
- all activities can be advanced
- will need to adjust program is RC tear repair was done as well
- flexion and elevation in the scapular plane 120-140 by week 6
- ER 30-45 obeying additional restrictions if RC repair
- Passive IR in wk 6 w/ arm in 60* abduction
What are the guidelines for phase 2 of rTSA rehab?
Early Phase 2:
- dislocation precautions will be enforced
- progression from PROM to AAROM in supine w/ scapular stabilization
- progression to sitting and standing
- rotational AAROM
Late phase 2:
- AAROM to AROM
- gentle strengthening
- week 8-9 being submax rotational isometrics
- progress deltoid and scapular exercises to available AROM
What are the guidelines for phase 3 and 4 of rTSA rehab?
Phase 3:
- initiate when appropriate P/AA/AROM achieved
- isotonic activation of deltoid and periscapular musculature
- resistive strengthening of the distal UE
- continue to follow dislocation precautions
- should be at 2-3# for PRE’s
- continue low weight/high reps
Phase 4:
- Usually the HEP phase with d/c criteria
- functional pain free AROM (typically 80-120 elevation/flexion and functional ER 30*)
- return to light household work with 10-15# limit
- Weight limit is for bimanual activities and should be followed indefinitely
What are the passive restraints for glenohumeral stability?
- bony geometry
- labrum
- capsulo-ligamentous structure
- negative intra-articular pressure
How can you classify glenohumeral instability?
-timing/frequency (acute vs chronic/recurrent)
-direction (uni/multidirectional)
-onset (traumatic/atraumatic/overuse)
-volition (voluntary vs. involuntary)
degree (subluxation vs dislocation)
What are the two general types of glenohumeral instability?
TUBS (traumatic-unidirectional-bankhart lesion-surgical; repair)
AMBRI (atraumatic-multidirectional-bilateral-rehabilitation-inferior capsular shift)
What is the most common MOI for anterior glenohumeral instability?
How is this different for posterior glenohumeral instability?
Inferior glenohumeral instability?
Posteriorly directed force to the distal forearm or hand w/ arm abducted and externally rotated
Posteriorly directed force with arm flexed and internally rotated
Inferiorly directed force with arm in abduction
How do you grade glenohumeral instability?
Normal: less than 25% of humeral head
Grade 1: 25-50% of humeral head
Grade 2: rides over head but spontaneously reduces
Grades 3: dislocation
What factors influence recurrence rate for anterior GH instability?
- age
- athletic participation
- length of immobilization
- rehabilitation
- time before return to sport
How long will shoulder be immobilized after anterior instability repair surgery?
Absolute immobilization for 0-4 wks followed by relative immobilization
How long after surgery until ROM should return to normal?
When can you being passive ER at 90* of abduction?
week 12
week 6
What are the goals of phase 1 of post-op management for anterior shoulder instability?
What are the precautions?
What are the criterion for progression for this stage?
Goals:
- protect the repair
- decrease pain and inflammation
- minimize scapular dysfunction
- staged ROM goals
Precautions:
- do not exceed staged ROM recommendations
- no lifting
Criterion for progression:
- adheres to post-op guidelines
- understands HEP
- achieves staged ROM goals
- minimal pain
What are the goals of phase 2 of post-op management for anterior shoulder instability?
What are the precautions?
What are the criterion for progression for this stage?
Goals:
- increase strength and endurance
- decrease pain and inflammation
- minimize scapular dysfunction
- staged ROM goals
Precautions:
- do not exceed staged ROM recommendations
- avoid activities in excessive ER that will stress anterior capsule
Criterion for progression:
- normal scapular mechanics
- independence w/ HEP
- achievement of staged ROM goals
- ROM and strength exercises completed w/o pain
What are the goals of phase 3 of post-op management for anterior shoulder instability?
What are the precautions?
What are the criterion for progression for this stage?
Goals:
- protect the repair
- decrease pain and inflammation
- minimize scapular dysfunction
- staged ROM goals
Precautions:
- continue to avoid undue stress on the anterior capsule
- do not initiate plyometric activities unless patient is returning to this type of activity
Criterion for progression:
- good understanding of anterior capsule stress and compromising positions for capsule
- independence w/ HEP and safe progression
- achievement of staged ROM goals
- Full ROM and strength
What milestones should be met before patients are able to return to activity or sport?
- clearance from physician
- no complaints of pain at rest and minimal w/ activity
- no or minimal sensation of instability w/ activities
- restoration of full functional ROM
- adequate strength and endurance of RC and scapular muscles to perform activities w/ minimal to no pain
- if pt. lacks confidence then a brace can be considered
How long does a patient who underwent posterior GH instability repair surgery need to be immobilized?
3-4 weeks of absolute immobilization followed by relative immobilization
What ROM and exercise guidelines should be met at the 1-6 week post-op mark?
6-12 wks post-op mark?
13-18 weeks?
1-6 weeks: -PROM in scapular plane -Limit elevation to 120* -Limit IR: 10-20* -Limit ER: 60-80* Exercise: AROM of distal extremity with arm in neutral
6-12 weeks: -limit elevation to 140* -limit IR: to 45* -Full PROM by 8-10 weeks Exercise: -initiate PRE's IR w/band from full ER to neutral -ER w/band from neutral to full ER -prone horiz. abd: limit to 45* of horiz. add
13-18 weeks:
-initiate posterior capsule stretch and IR stretch
-pain free full AROM expected by 4 months
Exercise: progress PRE’s w/o limitations
over 18 weeks: CKC ex w/ body weight and sport specific training
6 months: return to play
What is the surgical management strategy for GH multidirectional instability?
EUA to determine predominant direction of instability followed by surgery to correct the predominant direction of instability
What is the immobilization protocol for multidirectional GH instability rehab?
Absolute immobilization for 3-4 weeks in “gunslinger” position which is in abduction and slight ER followed by relative immobilization
What are the ROM guidelines at 1-6 weeks for multidirectional GH instability rehab?
6-12 weeks?
13-18 weeks?
1-6 wks:
- PROM in scapular plane
- limit elevation to 90*
- rotation limits will follow either the anterior or posterior protocol depending on concomitant procedure
6-12 wks:
- limit elevation to 120*
- limit rotation 30-40*
- Full PROM by 10 weeks
13-18 weeks:
- initiate full forward elevation and abduction
- pain free full AROM expected by 4 months
When can PRE’s be initiated post-op for multidirectional GH instability?
What exercise can be done at the 18 week mark?
at the 6-12 week mark
CKC ex w/ body weight and sport specific strengthening
When can an athlete generally return to sport after surgical repair of multidirectional GH instability?
Depends on type of instability shift but generally can return to sport within 4-6 months with contact sports being towards the end of that time range
unless the shift was an inferior capsular shift w/ an additional procedure then return to contact sports generally takes 8 months
