Week 4: Rotator cuff repair Flashcards
4 muscles of the rotator cuff
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Function of the supraspinatus?
Abduction
Function of the Infraspinatus?
External rotation
Function of the subscapularis?
Internal rotation
Function of the teres minor?
External rotation
What are the four types of rotator cuff tears?
Complete (full-thickness) tear
Bursal sided partial tear
Articular sided partial tear
Intra-tendinous partial tear
Provide 4 examples of when surgery is indicated for the shoulder?
- Acute traumatic full thickness cuff tear
- Traumatic dislocation +/- Hill-Sach & Bankart Lesion
- Adhesive capsulitis
- Recurrent dislocation
Article: Progressive exercise compared with best practice advice with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders.
Findings?
Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders.
Article: Treatment of non-traumatic rotator cuff tears (physiotherapy group, acromioplasty and physio group & rotator cuff repair, acromioplasty and physiotherapy group
Findings?
There was no significant difference in clinical outcomes between the three interventions at the two year follow up. Conservative treatment is a reasonable option for the primary initial treatment of isolated, symptomatic, non-traumatic, supraspinatus tears in older patients
When is surgery indicated for rotator cuff?
Failure of 3-6 month conservative plan OR
an acute full-thickness tear in active patient < 50/yo or significant weakness
What are the two surgical approaches for RC repair?
- Arthroscopic RC repair (camera guided through, surgery through 2-3 small slits).
- Mini open RC repair - Large or complex tears or reconstruction (tendon transfers). Potentially an incision/detachment of the deltoid
Influence of surgical approach on RC repair?
- Open/Mini open = deltoid muscle detachment is needed to gain access to rotator cuff. This can affect the muscle’s ability to contact actively for 6-8 weeks post surgery.
- Arthroscopic = minimal/no deltoid involvement (smaller incision)
Influence of the size of the tear on rehabilitation?
Small (<1cm)
Medium (1-3cm)
Large (3-5cm)
Massive (>5cm)
- > 5cm = poorer outcomes.
Note: retracted tears = greater mobilisation of the muscle
Influence of tissue quality on rehabilitation?
Tissue quality can be good, adequate or poor
If the tissue quality is good, more aggressive rehabilitation strategies may be used because the tissues are better able to handle the stress and strain of more intense rehabilitation exercises.
Quality of muscle (eg weak), tendon and bone also important. MRI can assess this before surgery
Influence of the location of an RC tear on rehab?
- Tears that extend to involve posterior cuff structures (infraspinatus and teres minor) require greater protection and restriction in excessive shoulder internal rotation motion (strain on site).
- Subscapularis tears
- Restrict the amount of external rotation motion until early tissue healing has occurred
Influence of the type of tear on RC rehab?
- Cresent shaped
- U shaped
- L shaped
- Retracted
- Retraction occurs proximally – Difficult repair due to tissue tension. Rehabilitation should be more conservative.
Influence on the type of tear on RC rehab (Acute vs gradual wear?)
Acute = 5%
Gradual wear = 95%
- Stiffness is higher following acute tears. And when other procedures, such as a superior labrum anterior and posterior (SLAP) are performed concomitantly (rehab is more aggressive in these patients)
Influence of timing of surgery on RC rehab?
- Patients with immediate surgical repair progressed more rapidly in their rehabilitation than delayed surgical repair
Influence of surrounding tissue quality on RC rehab?
- Remaining rotator cuff tissue anterior and posterior to the tear is important eg supraspinatus the sub scap and infra/teres minor quality is important as these muscles play a role in humeral head compression and stability
- If quality is fair – poor, consider a more conservative post-surgical rehabilitation protocol
Influence of patient characteristics on RC rehab?
- Age, smoking, type II diabetes, worker compensation
- Older patients – Tissue quality reduced AND tendon to have larger tears and more complex abnormalities
- Worker compensation – Patients with worker compensation required 2 x more time to return to work
- Active patients pre-injury have better outcomes post surgery
Influence of access to care on RC rehab?
- Patients treated by physiotherapist generally have better outcomes than patients with home-based programs
Surgeons philosophical approach on RC rehab?
- Conservative or aggressive
- Obviously, this will affect rehabilitation time
Main precautions in phase 1 RC tear repair?
- No pushing pulling or lifting (no heavy lifting for 4–6/12)
- No shoulder extension, horizontal adduction or IR
- No overhead motions
- No excessive stretching or sudden movements
- No supporting BW through hands or leaning on elbows
- Don’t sleep on affected side
- Wound Mx
- Keep incisions dry/Use Shower sling
Main goals in phase 1 RC repair?
Goals
* ↓ pain, inflammation, oedema
* Maintain integrity of repair
* Control pain
* Maintain and improve distal muscle strength
* ↑ PROM as tolerated
* Maintain ROM of cervical spine, elbow and wrist
