Rehabilitation Guidelines for Shoulder Arthroscopy

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1 Rehabilitation Guidelines for Shoulder Arthroscopy 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. Labral tears and rotator cuff tears are often caused by a direct injury to the shoulder, such as falling on an outstretched hand. However, the labrum and rotator cuff also can become torn from gradual wear and tear of the shoulder. These tissues can cause pain and catching with shoulder movement. Shoulder arthroscopy may be performed using small instruments inserted through <1cm incisions in the shoulder, to debride loose tissue and tears. Subacromial impingement occurs when the rotator cuff tendons and/ or bursa become trapped between the acromion and the humerus with overhead motion of the shoulder. Shoulder Pain A subacromial decompression is an arthroscopic procedure performed when small instruments are used to remove bone on the undersurface of the acromion to create more space for the rotator cuff tendons. Often there is a bone spur in this region that can pinch against the rotator cuff or bursa (fluid filled sac) causing the pinching or impingement. Acromioclavicular (AC) joint symptoms are another common shoulder problem, resulting from both direct injury to the AC joint and rotator cuff impingement. A Cambridge, MA Phone:

2 Mumford arthroscopic procedure resects the distal clavicle in cases of posttraumatic degenerative disease of the AC joint and shoulder impingement syndrome. Chronic injury to the long head of the biceps can also be a pain generator in the shoulder. The tendon can often become frayed or partially torn. In some cases the surgeon may release the long head of the biceps to relieve the pain. This is called a biceps tenotomy and is done arthroscopically. 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. Arthroscopic Surgery Rotator Cuff Anatomy 2

3 PHASE I (usually surgery to 3 weeks after surgery) Rehabilitation appointments begin within 7 days after surgery Reduce pain and swelling in the post-surgical shoulder Regain full passive range of motion (PROM) and active assistive range of motion (AAROM) Activation of the stabilizing muscles of the gleno-humeral and scapulo-thoracic joints Avoid activities that may impinge on the bone of the acromion Use sling as needed for comfort Relative rest to reduce inflammation Begin 7 days after surgery, sub-maximal shoulder isometrics for internal rotation/external rotation, flexion/extention and abduction/adduction Shoulder AAROM/PROM: Codman's, pulleys, cane exercises in all planes of motion except horizontal adduction (these should stay relatively pain free) Gentle shoulder mobilizations as needed Hand gripping Elbow, forearm, and wrist active range of motion (AROM) Cervical spine and scapular AROM Postural exercises Walking, stationary bike Avoid running and jumping due to the forces that can occur at landing Progression Criteria Progress to Phase II when they have achieved full PROM and normal (5/5) strength for internal rotation/external rotation with arm at side 3

4 PHASE II (begin after meeting Phase I criteria, usually 4-5 weeks after surgery) Progression Criteria Rehabilitation appointments are once every 1-2 weeks, if needed Controlled restoration of AROM Strengthen shoulder and scapular stabilizers in protected position (0-45 abduction) Begin proprioceptive and dynamic neuromuscular control retraining Correct postural dysfunctions Avoid repetitive overhead activities Post-rehababilitation soreness should alleviate within 12 hours of the activities AROM in all cardinal planes--assessing scapular rhythm Gentle shoulder mobilizations as needed Rotator cuff strengthening in non-provocative positions (0-45 abduction) Scapular strengthening and dynamic neuromuscular control Cervical spine and scapular AROM Postural exercises Core strengthening Walking, stationary bike, Stairmaster Avoid running and jumping until athlete has full rotator cuff strength in a neutral position due to forces that can occur at landing Progress to Phase III when they have achieved full AROM (equal to uninvolved side) and normal (5/5) strength for internal rotation/ external rotation with shoulder at 45 degreed abduction 4

5 PHASE III (begin after meeting Phase II criteria, usually 7-8 weeks after surgery) Progression Criteria Rehabilitation appointments are once every 2-3 weeks Normal (5/5) rotator cuff strength at 90 abduction and with supraspinatus testing Full multi-planar AROM Advance proprioceptive and dynamic neuromuscular control retraining Correct postural dysfunctions with work and sport specific tasks Post-rehabilitation soreness should alleviate within 12 hours of the activities Multi-plane AROM with gradual increase in velocity of movement - assessing scapular rhythm Gentle shoulder mobilizations as needed Rotator cuff strengthening at 90 abduction, provocative positions and work/sport specific positions Scapular strengthening and dynamic neuromuscular control in overhead positions and work/sport specific positions Cervical spine and scapular AROM Postural exercises Core strengthening Begin education in sport specific biomechanics with very initial program for throwing, swimming or overhead racquet sports Walking, stationary bike, Stairmaster, running Avoid swimming until athlete has normal (5/5) rotator cuff strength at 90 abduction and negative impingement signs Progress to phase IV when they have achieved full multi-plane AROM (equal to uninvolved side) and normal (5/5) strength for internal rotation/external rotation with the shoulder at 90 abduction and full supraspinatus strength 5

6 PHASE IV (begin after meeting phase III criteria, usually weeks after surgery) Progression Criteria Rehabilitation appointments are once every 2-3 weeks Normal rotator cuff strength at 90 abduction and with supraspinatus testing 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 Multi-plane AROM with gradual increase in velocity of movement - assessing scapular rhythm Shoulder mobilizations as needed Rotator cuff strengthening in at 90 abduction, 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 Return to sport/full-activity after receiving clearance from the orthopedic surgeon and rehabilitation therapist. This will be based on meeting the goals of Phase III 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. 6

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