Rotator Cuff Tears Our approach

Transcription

1 Rotator Cuff Tears Our approach Terry R. Malone EdD., PT, ATC Professor of Physical Therapy University of Kentucky Nothing to disclose only wish

2 Deep Musculature & Glenoid

3 RC Insertion Data The RC insertion is special Tendon to bone involves a quasilinear viscoelastic model significantly different at tendon region versus bone true of viscous and many other biomechanical measures- This tissue varies as to viscoelastic properties, collagen structure, and extracellular matrix composition. Thomopoulos, et al -JOR

4 Thomopoulos JOR

5 Reality of the Cuff Small muscle-tendon units Normal tendon doesn t tear (thus much of what we witness tendinopathy / tendinosis NOT tendonitis) We can have problems due to things rubbing on top (Bursal Side) or more related to tendon load (Articular Side) Never as good as it was (insertion site and FI) Rule: more anchors = more $ s

6 Role of the Cuff 1) Keep Head of humerus properly positioned (Keep it centered) Best terminology is Compression 2) Work in force couples to maintain proper positioning to enable the wonderful ROM of the GH Joint but really the Shoulder Complex

7 Old Concepts SS Humeral head Depressor & initial abductor

8 Cuff Mechanics Rotation plays a role Wakabayashi JSES 2003 & Ahmad AJSM 2008 (neutral position least stressful ) Anterior 1/3 most important in loading Itoi JOR 1995 Margin convergence & tension important in surgical management Cole et al JARR 2007

9 Cuff Recovery Not everyone needs surgery Getting to where it can go must be balanced with tension (8 lbs. or less Davidson JSES 2000) Foot print is good but limited data showing superiority (Bridge/Double Row/Single Row) Pillow sling but you do need to go to 0 - & - using the pillow may just delay the issue Rehab- go slow early ROM may be OK but the gains may not be worth the risks Strength takes time 6-&-12 month Rules

10 Head Stays Centered Primarily Spin/Rotation Same Contact to Glenoid About 3 mm

11 Why does it become Degenerative? CUFF ATTRITION

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13 VASCULARITY (Not everyone agrees!) Classic Work Rathbun & Macnab JBJS (B) 1970! Concerns Are Related to CONSTANT LOADING wringing out

14 Tendon via size-length Small < 1 cm Medium 1-3 cm Large 3-5 cm Massive > 5 cm (Not always easy to quantify S/M uniformly good Large Solid BUT Massive not as predictable- Sup. Capsular Reconstruction)

15 Motion Limits OK But Pain at Night No One s Delight

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17 LAWN MOWER HERE Chain saw- Out board Motor or SNOWBLOWER our world

18 Patient CODMAN-PENDULUM Reality

19 You support the weight of the involved- (other hand) may be done standing or flexed at waist

20 Interesting Factoid Eccentric Pain Greater than Concentric

21 Important Rehab Factoid Pillow Prop Pattern

22 Tenets for Rotator Cuff Type of Surgery- Talk to surgeon!!! Deltoid, size, Open Mini - Scope Fixation - Suture, Anchor, Bridge What makes sense - Talk to surgeon!!! Quality of Tissue (smoking & diabetes) Specifics of Case Other pathologies i.e- Biceps Tenodesis This Means: keep elbow flexed early - & minimize elbow (isolated biceps) loading

23 So Question 1 When to move Since 2000 more p/o RC protocols have been promulgated with early introduction of active motion An interesting question: has this led to increased re-rupture rates or is it just having the MRI [Remember: often no outward or clinical sign of re-rupture]

24 Does early motion help ROM? Uncomfortable answer is it may not matter that much (Kim ; Lee 2011 & 2012) No difference in 6 month data Early vs 4-6 weeks of immobilization I do recommend NOT GETTING ACTIVE too early based on what we have seen in the literature over last 10 years

25 When do failures occur p/o? Within the 1 st three months and fairly common (>40%) in large and massive tears Miller et al 2011 AJSM Overall failure rate of 33% and 74% of all failures were atraumatic in the 1 st three months p/o Kluger et al 2011 AJSM

26 Reality on Strength 6 months ~ % of nonsurgical - takes 9-12 months to get to within 10-15% of normal (S/M >L) Walker et al JBJS 1987 Small & Medium tears >L/Massive UCLA scores & ~70% power /80% 6 months least 1 year to ~ normal Rokito et al JSES Vol 5 # Hence 6 & 12 Month Rules!!!

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31 Single Row vs Double Row

32 Suture Bridge Construct

33 Normal Biomechanics Centered Humeral Head (Rotator Role) Proper Sequence of Recruitment Balance of Active & Passive Structures Proximal Stability Neuromuscular Integration SO will it ever be NORMAL???

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35 Active Exercise Must Be: Painfree!!!

36 Rehabilitation Rules 6 & 12 Month Rule 6 Months to have the Motion and 12 Months to have the Power to use the Motion (Gain 10-20% during this time) Walker et al JBJS

37 PRE Progression Multiple Angle Isometric - Submaximal to Maximal Efforts Isotonic Restricted ROM - Concentric & Eccentric Efforts - (Progression of ROM) Isokinetic - Speed and ROM Progressed- In the post-operative patient PNF patterns - The Resistance and Speed are Controlled! If Biceps Tenodesis...

38 Movement Progression Passive (PREVENT adaptive shortening maintain glides Keep it moving!) Assistive Assistive - Active Active (Gravity Minimized) Active (Lever arm controlled) Keep the Elbow Flexed!!! Tenodesis... Concentric and Eccentric Actions

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40 Alter the Medium Gravity - Elbow Flexion Water - Slide Boards - Positions Resistance Speed Keep the Elbow Flexed Early - Nice to begin with Passive Actions of this Nature you could call it an Assistive Codman

41 Factors Relating to Success Age of Patient and Onset of Injury Traumatic vs. Degenerative Size of Tear Surgical Procedure (Deltoid - open ) Work or Activity Levels (Remember Smoking and Workers Comp. Insurance) Specifics of Patient (Motivation, tissues) Remember - You can only do so much!

42 General Rules Six to Eight Weeks before Active - on to - Resistive Motion can be introduced (may be early in some cases) Scapular plane best position (Roll into Abduction/Adduction plane) Patient/Assistive Codman works well High ROM should be used but with care- We often say in house use only Remember the Blame Game

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44 General Time Frames (Post - Operative) Phase 1- Three to Eight Weeks Phase 2- Six to 12/16 Weeks Phase 3-15 to 24/30 Weeks Phase 4- Six months through one year

45 Rehabilitation Phases Phase 1- Primary Healing, Passive Motion & Pain Modulation Phase 2- Active Motion, Normalization of ROM Phase 3- Strengthening Isolated- Integrated-Functional Progression Phase 4- Advanced as required by patient- Sport Activities

46 Rehabilitation Implications Favorite Stretching Exercises Always: Increase temperature (actively or passively) Remove the ER-MTU if working on the Posterior Structures (Do a Manual technique or PNF)

47 Post-Operative Concepts Primary Rules Protect the Repaired Tissue Restore ROM (Passive & GH/ST Pattern) Restore Muscular Control (ST then GH) (Turn on the individual muscle {pain}) Restore/Enhance Dynamic Patterns

48 Post-Operative Concepts Another concept is use of: Unloading or Supported Movements Have the patient slide the arm Often start with forearm on Table/counter Top Increased to hand/wrist - seated and standing patterns used!!!

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50 Reality Be Careful Respect Tissues IT TAKES TIME!!!

51 Reality is important! Poor Tissues - Be careful out there! Strength take time! 6-12 month rules! Know the surgeon and surgery! You can only do so much!

52 So what to avoid! #1 No specific time point for progression patient must recognize It will take time & progress is sometimes slow #2 Not easily predicted BUT as a general rule Small & Medium tears strong fixation and good quality tissues do progress more rapidly and easily #3 Remember: Smokers, Diabetics, and Workers Comp do less well!

53 Remember: Tissues can only take it so long!

54 Thank You If you ever want to