SLAP Lesions Rehabilitation Concepts

Transcription

1 SLAP Lesions Rehabilitation Concepts Kevin E. Wilk, PT, DPT, FAPTA Glenoid Labral Lesions Introduction Classification of SLAP tears Andrews & Carson: AJSM 85 Snyder: Arthroscopy 90 (Type I IV) Maffet et al: AJSM 95 (Type V- VII) Powell et al: Op Tech Spts Med 04 (Type VII- X) Tokish et al: JBJS 09 (circumference tear) Often not an isolated lesion Glenoid Labral Lesions Introduction Common injury - difficult to diagnose May occur in isolation or in combination SLAP lesions: Snyder: Arthroscopy 90 Andrews: AJSM 85 Difficult to diagnose» subtle symptoms, pain, popping» can cause disability» prolonged symptoms O Brien: AJSM 98 JOSPT 05 JOSPT 13 IJSPT 13 Glenoid Labral Lesions Introduction Common injury - Can lead to functional limitations Functional disability Can t perform at a high level Wilk, Reinold: JOSPT 05 Often pain is limiting factor Maffet, Gartsman: AJSM 95 Mechanical pain alleviated with rest Pain during specific movement Throwing, lifting overhead, etc Wilk, Reinold: JOSPT 05 Glenoid Labral Lesions Clinical Outcomes Neri et al: AJSM 11 SLAP type II repairs in overhead athletes 57% returned to pre-injury level Patients with cuff pathology poorer outcome Neumann et al: AJSM 11 SLAP type II repairs in overhead athletes 84% returned to pre-injury level Mixed subject pool of various sports

2 Glenoid Labral Lesions Clinical Outcomes Sayde et al: CORR 12 Systematic review SLAP type II repairs 14 studies & 506 patients Overall 83% good excellent results 63% overhead athletes returned to sports 73% returned to pre-injury level Anchor repairs did the best Weber et al: AOSSM 2010 SLAP Lesions :Incidence rates, complications & outcomes as reported by ABOS part II candidates 6 month case list to ABOS 4975 SLAP repairs 9.4% of all shldr cases Mean age of male patients 36.4, 78% male Mean age of female pts 40.9 Pain was reported absent in only 26% Function restored as normal in only 13% 40% of patients reported an excellent result Glenoid Labral Lesions Clinical Outcomes Gorantla et al: Arthroscopy 10 Systematic review SLAP type II repairs No level I or II studies Overall 40-94% good excellent results 22-64%% overhead athletes returned to sports Overhead athletes most challenging Outcomes of Non-Operative Rx SLAP Based on these findings, a trial of nonoperative treatment may be considered in patients with the diagnosis of isolated superior labral tear. In overhead athletes and in those patients where pain relief and functional improvement is not achieved (by rehab), surgical treatment should be considered. SLAP Repairs Then & Now Outcomes of Non-Operative Rx SLAP 371 pts surveyed 39 included in study (returned data sheets) Only 19 actually managed with non-operative treatment 66% return to same level overhead sports

3 Real Question: What causes the Pain? SLAP symptoms are difficult to pinpoint Rotator Cuff may be the Real Problem Pain generator: SLAP?, Cuff?, Biceps? Biomechanics of the Biceps/labral complex are Very Poorly understood Biceps as a Pain Generator Sports Med Arthrosc Sep;16(3): it seems that isolated arthroscopic biceps tenotomy or tenodesis is a valuable option for the treatment of rotator cuff tears in selected patients. Although it does not improve shoulder strength, tenotomy or tenodesis reduces pain and improves the functional range of motion with a high degree of patient satisfaction. Treatment Decisions for SLAP Lesions What else can you do? SLAP debridement? Biceps tenotomy, tenodesis? Posterior capsular release? Anterior plication? Non-operative rehabilitation Nothing? Tell him to give up baseball? Biceps Tendon Pain Receptors Investigated the presence of sympathetic innervation and α1- adrenergic receptors of the long head of the biceps brachii tendon (LHB) A strong correlation between the expression of NPY/S-100, α1-adrenergic/s-100, and α1-adrenergic/npy was found. The LHB tendon has sympathetic innervation and α1- adrenergic receptors in acute and chronic pathological conditions. Question? Glenoid Labrum Anatomy What should we do with the Proximal Biceps Tendon?

4 THE BICEPS-LABRAL COMPLEX Vangsness et al: JBJS (B) % of biceps tendon arose from supraglenoid tubercle, remaining from superior labrum Slightly more common for biceps to attach slightly posteriorly Right Shoulder 3 THE GLENOID LABRUM Vascularity Originates from suprascapular, circumflex scapular branch of subscapular, & posterior circumflex humeral Mainly peripheral blood supply Superior & anterosuperior less vascularity Vascularity decreases with age 12 Anatomy, Histology, and Blood Supply Right Shoulder

5 Mechanisms of SLAP Lesions Glenoid Labral Lesions Traumatic Lesions Glenoid Labral Lesions Traumatic Lesions Fall onto outstretched arms Forceful abduction diving (diving) Weightlifters Pushing heavy objects Blow to the shoulder Glenoid Labral Lesions Traumatic Lesions

6 Glenoid Labral Lesions Micro-Traumatic Lesions Repetitive stresses during throwing (microtraumatic) Anterosuperior lesion, near biceps During follow-through phase *Arthroscopy of 73 throwers 83% exhibited a Labral lesion Andrews, AJSM 85 *Throwers undergoing TCS: 91% labral pathology Wilk,Reinold,Andrews:JOSPT 02 Andrews, Wilk, Reed et al: Spring Trn asymptomatic professional baseball pitchers tested at onset spring training MRI of glenohumeral joint 28/31 (90 %) abnormal glenoid labrum 27/31 (87 %) abnormal rotator cuff appearance 12/31 (39%) humeral head changes All pitchers were pain-free at time of study All MRI scans assessed by radiologist Miniaci et al:ajsm 02 Examined 14 asymptomatic professional pitchers Performed MRI & clinical examination 79% exhibited abnormal glenoid labrum 79% exhibited changes of the supraspinatus tendon Humeral head changes were seen in 36% (cystic changes) Biceps Pain with Suspected SLAP Overview Some patients complain of biceps pain when a SLAP lesion is suspected What is the cause of biceps pain How to Rx the biceps pain? Non-operative Rx plans:

7 SLAP Classification Glenoid Labral Tears SLAP Lesions The peel back mechanism Type II SLAP lesions Burkhart, Morgan: Arthroscopy 98 SLAP Classification (I-X ) Glenoid Labral Tears SLAP Lesions Type II Peel Back Lesion» Three types of subclasses IIA: Anterior type III IIB: *posterior type II IIC: combined anterior & posterior type II Burkhart, Morgan: Arthroscopy 98 Arthroscopic SLAP Pathology Type II Glenoid Labral Tears SLAP Lesions Type II peel back mechanism Torsional force of biceps labrum as arm abducts & ER Change in biceps vectors from anterior horizontal to vertical & posterior???

8 SLAP Lesion Arthroscopic View Overhead Throwing Athlete Partial Undersurface Infraspinatus Tear Posterior Labral Detachment With Peel-Back Shepard,Dugas,Zheng: AJSM 04 8 fresh frozen cadavers Ultimate strength of biceps labrum complex. SLAP lesion mechanism Two loading patterns:» Eccentric force(force in line)» Late cocking loading (ER in Abd) Ultimate tissue strength: eccentric: 508N cocking : 262N All failures appeared as SLAP type II lesions 360 Type Avulsion of the glenoid labrum around the entire glenoid traumatic mechanism 59 patients thus far

9 Gobezie, Millet, Cole, Warner: AJSM 08 Interobserver & intraobserver variability in the diagnosis & treatment of SLAP tears 22 video vignettes sent to 73 surgeons Asked to classify & provide Rx approach Results: Trouble distinguishing normal labrum from type II Trouble distinguishing Type III from Type IV Type III lesions is much more variable than others SLAP Lesions Rehabilitation Guidelines SLAP Lesions Surgerical Treatment Type I: Debride back to stable rim Type II: Reattach superior labrum to glenoid, stabilize biceps anchor Type III: Torn fragment resected, leave remaining stable tissue Type IV: Treatment base on extent of biceps tear» Less than 30%: torn tissue resected» Greater than 30%: biceps repair (age) SLAP Lesions Non-Op Rehab Guidelines Determine extent of lesion:» Fraying vs Detachment» Concomitant lesions (cuff, capsular) Non-Operative Rehabilitation Guidelines Reduce inflammation & pain Normalize motion (esp. IR) Re-establish dynamic stability Improve scapular posture & NM control Correct biomechanical factors sports Gradual return to sports SLAP Lesions Surgerical Treatment Type V: Repair Bankart lesion & reattach superior labrum SLAP II Type VI: Excise or debride unstable flap tear & reattach superior labrum detachment SLAP II Type VII: Repair anterior capsule (MGHL) and reattach superior labrum SLAP Lesion Rehabilitation Normalize Motion & Stretching Consider the total motion concept Caution when stretching into ER!!! Do stretch into IR & Horizontal Adduction - Posterior Structures **Critical to successful rehab STRETCH!!! Adjust intensity of stretch to player s laxity & inflammation!!

10 Modified Sleeper s Stretch Wilk et al: JOSPT 13

11 Modified Side-Lying Cross Body Stretch Wilk et al: JOSPT 13 Re-establish Dynamic Humeral Head Control

12 Improve Scapular Position, Posture, & Scapulothoracic Control

13 Advanced Thrower s Ten Program

14 Rehabilitation of the Thrower s Shoulder Functional Drills Stretching & ROM Thrower s ten program Plyometric drills Interval throwing program:» long toss» interval mound throwing» Gradual return to competition Rehab Overhead Thrower Functional Drills Interval Throwing Program How far should a player throw??? Pitcher vs position player Should pitchers throw further than 120 ft??? From 120 feet progress to off the mound program Normalize biomechanics Interval Throwing Program Long Toss Program Suggested application» Gradually increase distance» feet??? Advantages» Arm strengthening» Flexibility (get loose) Disadvantages:» Ball release point» Differences in mechanics Is Throwing Longer Better??

15 Rehabilitation of SLAP Lesions Non-Operative Treatment Correct biomechanics flexibility, strengthening, endurance training & skill training Gradual Return to Play with a program to follow Rehabilitation Following SLAP Surgery SLAP Lesion Repair Rehab Guidelines Rehabilitation must match the surgery» Repair vs. Debridement Based on type of lesion» SLAP classification I thru IV (VIII) Based on severity of SLAP lesion Consider patient s age Emphasis on dynamic stabilization Do not overstress healing tissue (excessive ) Minimize biceps activity (II, IV) Repairs Microtrauma injury - *think dynamic stabilization!!!

16 SLAP Lesion Rehab Type I & III Sling for comfort 3-4 days Isometric (all planes) 7 days TYPE I TYPE III Immediate ROM exercises» Full ROM days Isotonic strengthening day 8» Wt resistance increase 1 lb/wk» Light biceps for 2-3 wks» Scapular strengthening SLAP Lesion Rehab Progress Strengthening Program Debridement Type I SLAP Emphasize muscular balance Manual resistance drills Rhythmic stabilization end range Isotonic strengthening Trunk and leg training» Core stabilization SLAP Lesion Rehab Type I & III Immediate motion AAROM, PROM to tolerance: ER / IR scapular 45 Flexion ROM to tolerance ER / 90 deg. Abduction» Usual at day 4-5 Full ROM days* Re-establish Dynamic Humeral Head Control

17 SLAP Lesion Rehab Establish Muscular Balance Emphasize muscular balance» ER/IR ratio: 62-72%» ER/ABD ratio: 64-69%» ABD/ADD ratio: 66-72% Emphasize ER & scapular muscles Wilk: AJSM 93 Wilk: AJSM 95 Rehab Following Rotator Cuff Debridement Critical Factors Depth of cuff lesion:» Small: 15% or less» Moderate: 15-40%» Significant: 40% or greater Location of lesion:» Involved muscles supraspinatus,infraspinatus» PASTA Lesions (Snyder 03) Rehab Following Rotator Cuff Debridement Classification Partial Thickness tears Small tears: 15% or less Moderate size: 15 40% Significant tears: 40% or greater 50% or greater Treatment Based on Classification Determines Rate of Rehabilitation SLAP Lesion Rehab Type I & III Isotonic strengthening weeks 3-8 Progress to weight training weeks 4-6 Plyometrics week 4 to 5 Primary goal muscular balance & dynamic stabilization Initiate Interval Sport Programs week 4-10:» Interval Sport Programs Dependent on concomitant lesions Especial rotator cuff lesions (under) Rehab Following Rotator Cuff Debridement Throwing Progression Interval Throwing Program Progress gradually to ITP when appropriate Specific criteria Small tears: week Moderate tears: wk Significant tears: wk Variable timeframes Gradually Progress to Mound Throwing

18 Rehab Following Rotator Cuff Debridement Throwing Progression Criteria to Progress to Throwing: Full Non-Painful ROM Satisfactory clinical exam Satisfactory isokinetic test Appropriate rehab progression Adequate healing timeframes Gradually Progress to Throwing SLAP Lesion Rehab Type I & III SLAP Repair 1999 Key to successful treatment*» symptomatic SLAP lesion with no associated instability Andrews: Orthop. Trans. 84» 73 throwers Rx debridement» 88% improved - returned to throwing 1 year» What about year 2 or 3??? SLAP Repair 2014 Biceps anchor Posterior Superior Labrum Glenoid TYPE II TYPE IV

19 Squeaking SLAP 11 months later Type II SLAP After Repair Appropriate Rehabilitation Program

20 REHABILITATION FOLLOWING SLAP REPAIR Factors Influencing Rehabilitation How quickly & aggressively can you be with a patient with a SLAP repair??? Rehabilitation Following SLAP Repair Precautions That s Self-Confidence Rehabilitation Following SLAP Repair Overview *Concern is to control forces/loads on repaired labrum ER/IR motion usually Not a problem no excessive motion for 12 wks* Restoration of full arm elevation (flexion) sometimes difficult Determine extent of lesion*» Number of suture anchors used» Location of lesion Ensure dynamic stability is present Rehabilitation Following SLAP Repair Precautions No CKC exercise drills till 8 weeks post-operative No resisted movements above 90 degrees elevation for 8 weeks No heavy bench press, heavy lifting overhead till 3 months post-operative Rehabilitation Following SLAP Repair Precautions Control forces for 6-8 weeks No overhead movements (above 90) for 3-4 weeks Need stable glenohumeral joint Emphasize dynamic joint stability» Minimize GH translation No isolated biceps 8 weeks» No heavy lifting Rehabilitation Following SLAP Repair Precautions Caution with aggressive IR stretching esp sleeper stretch

21 Rehabilitation Following SLAP Repair Range of Motion Progression Sling for 3-4 weeks» Sleep immobilizer 4 weeks Immediate limited motion» AAROM / PROM flexion to 70 0» Weeks 2-4: flexion to 90 Motion above 90 begins week deg abd. Week 5 Full normal ROM week 8 Week 8-12: return to throwers motion ER to 115 deg Rehabilitation Following SLAP Repair Weeks 3-4 Remove ROM restrictions Gradually increase ROM» Flexion to tolerance ER/IR at 90 0 ABD Full week 7-8» abd to » in overhead athletes Progress isotonics» thrower s ten program Rehabilitation Following SLAP Repair Range of Motion Progression Sling for 3-4 weeks» Sleep immobilizer 4 weeks Shoulder immobilizer for protection REHABILITATION FOLLOWING SLAP REPAIR Factors Influencing Rehabilitation Rehabilitation Following SLAP Repair Full ROM by week 6-9 ER to 90 0 by week 6-7 ER to by week 7-8 ER to 115 at week Plyometrics week 8» 2 hand plyos week 8-10» 1 hand plyos week 12 No CKC drills for 8-10 weeks Isolated biceps: initiate week 8» Light & progress

22 Rehabilitation Following SLAP Repair Muscular Training Isometrics immediately sub program!! Active ROM week 3 Light isotonics week 4-6 No isolated biceps for 8 weeks No CKC exercises for 8 weeks Advanced strengthening wk Plyometrics week Interval throwing week 16 (toss) Interval mound throwing program 5-6mos Interval hitting program week SLAP Lesion Rehab Type IV SLAP repair with biceps repair or tenodesis No biceps for 12 weeks No stress on biceps for 3 months Strengthening for elbow flexion, light isometrics week Full activity w / biceps week Rehabilitation Following SLAP Repair Muscular Training Complications of Biceps Tenodesis The incidence of complications after subpectoral biceps tenodesis with interference screw fixation in a population of 353 patients over the course of 3 years was 2% Rehabilitation Following SLAP Repair Functional Activities Proximal Humerus Fracture after Biceps Tenodesis Initiate throwing program week 16» ITP long toss: week 16» ITP mound program week 22-26» Competitive throwing: 7-9 months» Interval Golf week 14 Athletes must continue ROM & strengthening program Return to sports:» Overhead sports: 6-9 months

23 Proximal Humerus Fracture after Biceps Tenodesis Rotator Cuff Tear with Anterior Instability Case Illustration: 18 yr old HS baseball pitcher and football linebacker Type IV SLAP Full Thickness RCT Anterior Labral Detachment Tenotomy or Tenodesis: is it the Future? Arthroscopic Treatment: 7 biodegradable anchors Repair of SLAP Lesion Arthroscopic Repair of Capsulolabral Lesion SLAP Repair with Concomitant Procedures??? 28 yr old professional football quarterback traumatic 330 SLAP with full thickness supraspinatus tear??

24 9 anchors Case Study 330 SLAP Rehab Following SLAP Repair with Concomitant Surgical Procedures SLAP repair with stabilization surgery Thermal capsular shrinkage Bankart repair (type V) Capsular shift or plication SLAP repair with cuff repair Arthroscopic or open repair SLAP repair with decompression SLAP with debridement Case Study 330 SLAP JOSPT 13 Rehab Following SLAP Repair with Concomitant Surgical Procedures SLAP repair with stabilization surgery Thermal capsular shrinkage Wilk, Reinold, Andrews: JOSPT 05 Bankart repair (type V) Voos,Pearle, Mattern: AJSM 07 Capsular shift or plication SLAP repair with cuff repair Arthroscopic or open repair Voos, Pearle, Mattern: AJSM 07 SLAP repair with decompression Coleman, Cohen, Drakos: AJSM 07 SLAP with debridement Case Study 330 SLAP Starting QB for every game entire season 06 to 11 Lead team NFC Championship game 06 All Pro Team starting QB 06 Lead NFL passing yds 06 Team #1 total offense 06 QB rating 3 rd in NFL 06 Career year 06 2 nd best year 07 3 rd year 08 within 15 yrs all time NFL passing record SLAP in patients above 40 yrs of age? Above 50 yrs? Concomitant rotator cuff repair?

25 Franceschi, Longo, Ruzzini: AJSM 08 Comparison of rotator cuff repair with & without SLAP type II repair 2 groups:» 31 patients RTC repair with SLAP type II repair» 32 patients RTC repair with biceps teonotomy Follow up at 2.9 yrs: no significant difference between two groups, group II exhibited higher post-op UCLA scores Beware of SLAP repairs with concomitant procedures Stiffness Monitor Patient closely & adjust appropriately SLAP Lesion Rehab Summary Rehab must match surgery Repair vs debridement Type I & III, simple debridement Rehab for functional stability Type II & IV, (V VIII) control stresses No overhead motion for 4 weeks Control forces 8-12 weeks Suretac vs. suture anchor rehab Team approach to treatment Extent & location of SLAP lesion Concomitant pathologies - Cuff