Rehabilitation Guidelines for Large Rotator Cuff Repair
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1 Rehabilitation Guidelines for Large Rotator Cuff Repair The true shoulder joint is called the glenohumeral joint and consists humeral head and the glenoid. It is a ball and socket joint. Anatomy of the Shoulder The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone) and the clavicle (collarbone). Ligaments and tendons connect the bones. The part of the scapula that makes up the roof of the shoulder is called the acromion. Impingement may be caused by the shape of the acromion causing irritation on the rotator cuff during motion. The joint where the acromion and the clavicle join together is known as the acromioclavicular (AC) joint. If this joint is injured during a fall, the ligaments stabilizing the joint may be injured. This is called a shoulder separation. If the joint wears out, it may become arthritic and painful with motion. The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. The stability and movement of the shoulder is controlled by the rotator cuff muscles, with assistance from the ligaments, labrum and capsule. Rotator cuff tears can occur from repeated stress or from trauma. Throwing activities, repetitive overhead movements, or falls onto an outstretched arm can cause trauma to the rotator cuff. Patients over the age of 50 are more susceptible to rotator cuff tearing from a fall. Rotator Cuff Anatomy Tears are classified in many ways, but most commonly they are referred to as partial or fullthickness. Partial tears can occur on the articular or bursal side of the joint. Bursal surface tears occur on the outer surface of the tendon and may be caused by repetitive impingement. Articular sided tears occur on the inner surface of the tendon, and are most often caused by internal impingement or tensile stresses related to overhead sports. Full thickness or complete tears extend from one surface of the tendon all the way through to the other surface of the tendon. Since a full-thickness tear is complete, there may be some retraction from the pull of the muscles against the torn tissue. The degree of retraction and dictate the extent of the repair. In general, the more retraction, the more difficult the repair and recovery. The most common tendons of the rotator cuff that are torn are the supraspinatus and infraspinatus. Less commonly injured are the subscapularis and the teres minor.
2 If rest and therapy cannot relieve the symptoms of the tear, surgery mau be warranted. The primary goal of a rotator cuff repair is to restore the normal anatomy by approximating the rotator cuff tendon back to its normal attachment site on the greater tuberosity of the humerus. This is done by passing sutures through the tendon and then tying the tendon down to suture anchors that have been placed in the humerus. The degree of success for tears that are repaired is related to various factors, including tear size, the number of tendons involved, patient age, associated injuries and post operative rehabilitation. Rehabilitation is vital to regaining motion, strength and function of the shoulder after arthroscopic surgery. Initially patients may use a sling for comfort. During this time, range of motion exercises are started to prevent the shoulder from getting stiff and losing mobility. The rehabilitation program will gradually progress to more strengthening and muscle-control exercises. General time frames are given for reference to the average, but individual patients will progress at different rates depending on their age, associated injuries, pre-injury health status, rehabilitation compliance and injury severity. Restrictions or precautions may also be given to protect healing. 2
3 PHASE I (usually surgery to 2 weeks after surgery) Rehabilitation appointments begin within 7 days after surgery Reduce pain and swelling in the post-surgical shoulder Maintain active range of motion of the elbow, wrist and neck Protect healing of repaired tissues Use sling continuously except while doing therapy Relative rest to reduce in ammation Elbow, wrist and neck active range of motion Ball squeezes Pendulum exercises Passive range of motion for shoulder flexion and abduction (between 0 and 50) Walking and/or stationary bike with sling on No treadmill Avoid running and jumping due to the forces that can occur at landing 2 weeks postop 3
4 PHASE II (begin after meeting Phase I criteria, usually 2 weeks after surgery) Rehabilitation appointments are 1-2 times per week Controlled restoration of passive and active assistive range of motion Activate shoulder and scapular stabilizers in a protected position of 0 to 30 of shoulder abduction Correct postural dysfunctions Continue use of the sling for the first 4 weeks Wean out of the sling slowly based on the safety of the environment - weeks 5/6 No active abduction for the first 8 weeks in order to protect the repair Passive and active assisted range of motion for the shoulder in all cardinal planes (shoulder abduction should be passive only) Begin active range of motion for shoulder flexion and rotation at 4 weeks Isometric internal and external rotator cuff strengthening in non-provocative positions with the shoulder in 0 to 45 of abduction Scapular strengthening with the arm in neutral - Sidelying scapular protraction/ retraction resistance Cervical spine and scapular active range of motion Core strengthening Walking and stationary bike No treadmill or stairmaster Avoid running and jumping until the athlete has full rotator cuff strength in a neutral position due to forces that can occur at landing The patient can progress to phase III when they have achieved full passive range of motion (equal to the uninvolved side) and normal (rated 5/5) strength for the shoulder internal rotators and external rotators at 0 of shoulder abduction 4
5 PHASE III (begin after meeting Phase II criteria, usually 6 weeks after surgery) Rehabilitation appointments are 1 time per week Full shoulder active range of motion in all planes Normal (rated 5/5) strength for shoulder internal rotators and external rotators with the shoulder in 0 of abduction Correct any postural dysfunction Ensure that exercises are pain free and do not include long lever arms that will significantly change the torque throughout the motion Begin active scapular strengthening exercises. Continue with sidelying manual scapular stabilization program to include retraction and depression Resistive exercise program with GH joint supported: biceps, triceps, wrists Begin submaximal rhythmic stabilization in supine position Shoulder internal rotation and external rotation with theraband or weights that begin at 0 of shoulder abduction - gradually increase shoulder abduction as strength improves Isotonic resistive exercises: sidelying ER, prone extension, prone abduction to 45 degrees, supine IR, flexion to 90 degrees Low resistance/ high repetition program Progress to full PROM and AROM in all planes HEP with RC strengthening and therabands Walking and stationary bike No treadmill, stairmaster or swimming Avoid running and jumping until the athlete has full rotator cuff strength in a neutral position due to forces that can occur at landing Full shoulder active range of motion (equal to the uninvolved shoulder) and normal (rated 5/5) strength for shoulder internal rotators and external rotators at 30 of shoulder abduction 5
6 PHASE IV (begin after meeting phase III criteria, usually 10 weeks after surgery) Rehabilitation appointments are 1 time every 2 to 3 weeks Normal (rated 5/5) rotator cuff strength and endurance at 90 of shoulder abduction Advance proprioceptive and dynamic neuromuscular control retraining Correct postural dysfunctions with work and sport specific tasks Develop strength and control for movements required for work or sport Post-rehabilitation soreness should alleviate within 12 hours of the activities No overhead work or sports Begin submaximal isokinetic program for IR/ER in neutral position. Begin with #2 weight or elastic tubing Resistance bands in external and internal rotation (concentric and eccentric). External rotation resistance in side-lying position. Lateral raises: side-lying abduction limited to 45 degrees allows strengthening with minimal risk of impingement. Prone rowing, extension and horizontal abduction. Build muscle endurance. Walking, stationary bike, and stairmaster. Jog only if 5/5 RTC strength. No treadmill or swimming Full shoulder active range of motion in all planes and multi-plane movements Normal (rated 5/5) strength at 90 of shoulder abduction Negative impingement signs 6
7 PHASE V (begin after meeting Phase IV criteria, usually weeks after surgery) Rehabilitation appointments are once every 2 to 3 weeks Normal (rated 5/5) rotator cuff strength at 90 of shoulder abduction Normal (rated 5/5) supraspinatus strength Advance proprioceptive and dynamic neuromuscular control retraining Correct postural dysfunctions with work and sport specific tasks Develop strength and control for movements required for work or sport Develop work capacity cardiovascular endurance for work and/or sport Post-rehabilitation soreness should alleviate within 12 hours of the activities Multi-plane shoulder active range of motion with a gradual increase in the velocity of movement while making sure to assess scapular rhythm Shoulder mobilizations as needed Rotator cuff strengthening in 90 of shoulder abduction as well as in provocative positions and work/sport specific positions, including eccentric strengthening, endurance and velocity specific exercises Scapular strengthening and dynamic neuromuscular control in overhead positions and work/sport specific positions Work and Sport specific strengthening Core and lower body strengthening Throwing program, swimming program or overhead racquet program as needed Design to use work or sport specific energy systems The patient may return to sport after receiving clearance from the orthopedic surgeon and the sports rehabilitation provider. Return to sport decisions are based on meeting the goals of this phase Sport Specific Recommendations: o Golf chipping/putting at 3 months o Golf wedge shots and tennis ground strokes 4 months o No throwing, tennis serves or freestyle swimming until 6 months Please be aware that this information is not intended to replace the care or advice given by your physician or health care provider. It is not intended to be a substitute for professional advice. Call your health provider immediately if you think you may have a medical emergency. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any question you may have regarding a medical condition. 7
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UCLA OUTPATIENT REHABILITATION SERVICES! SANTA MONICA! WESTWOOD 1000 Veteran Ave., A level Phone: (310) 794-1323 Fax: (310) 794-1457 1260 15 th St, Ste. 900 Phone: (310) 319-4646 Fax: (310) 319-2269 FOR
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