Rehabilitation Considerations for Post-Operative Rotator Cuff Repair. Adam Shutts, MSPT

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1 Rehabilitation Considerations for Post-Operative Rotator Cuff Repair Adam Shutts, MSPT

2 Post-Operative Rotator Cuff Repair Delayed vs. early mobilization Differing rehabilitation strategies for different size tears Exercise selection and dosage when is enough PT enough?

3 Early vs. Delayed Motion After Repair Timing remains controversial No true interdisciplinary consensus Different protocols may require two, four, or six weeks of immobilization, or none at all Unprotected vs. protected ROM

4 Post-Op Healing vs. Post-Op Stiffness Concern about retear Concern about post-op stiffness Find a safe, effective balance in post-op rehab protocol

5 Retear After Rotator Cuff Repair Typically happens in first 3-6 months post-op As many as 70% of large to massive tears ( 5 cm) retear As many as 20% of small to medium tears ( 3 cm) retear Other risk factors for failure Tear size, tissue quality, fatty infiltration and atrophy of muscles, age, smoking, diabetes, high cholesterol, patient compliance

6 Retear After Rotator Cuff Repair Factors affecting repair integrity Poor compliance in first 6 weeks leads to 152x higher risk for retear Suture-to-tendon healing rates» 19-30% at 6 weeks» 29-50% at 12 weeks Bone-to-tendon nearly mature in animals at 15 weeks Approach normal strength and elasticity after 6 months Smaller tears ( 3 cm) show inherent potential to heal

7 Post-Op Stiffness Varying definitions in literature 100 flexion and 10 external rotation at 90 days post-op 100 flexion and 30 external rotation at 90 days post-op Incidence after arthroscopic repair Various studies report between 3% and 23% patients show ongoing stiffness after one year

8 Early Range of Motion Can help to decrease subdeltoid adhesions, especially prevalent in open and miniopen repairs In animals, ROM shown to increase Type-III collagen in early stages of tendon-tobone healing Galatz et al (2009) showed that complete removal of load is detrimental to rotator cuff healing

9 Early Range of Motion Most early literature advocating early PROM was based on studies of digital flexor tendon repair Flexor tendon repair is typically inter-tendonous, whereas rotator cuff repair is often anchored to bone Also based on open rotator cuff repair, which is performed much less frequently than arthroscopic repair

10 Early Range of Motion Chang et al (2014) showed early, unrestricted ROM provided increased flexion and external rotation at 3- and 6-month follow-up, but no functional difference for these patients Parsons et al (2010) shows that any stiffness resulting from early immobilization tends to moderate by one year post-op Multiple studies show no difference at one year follow-up in pain, ROM, or selfreported outcomes, when comparing immediate vs. delayed ROM

11 Systematic Review Kluczynski et al, published in 2014 in American Journal of Sports Medicine Systematic review to determine whether early vs. delayed motion affects retear rates

12 Kluczynski et al, Analysis 1 Four studies directly comparing early vs. delayed ROM Early ROM 13.7% retear rate (182 repairs) Delayed ROM 10.5% retear rate (171 repairs) No significant statistical difference

13 Kluczynski et al, Analysis 2 Comparison of 15 studies (788 repairs) examining early ROM and 10 studies (635 repairs) examining delayed ROM Analyzed retear rates in early vs delayed groups Categorized subjects by tear size and repair method

14 Kluczynski et al, Analysis 2 Findings Tear size <1 cm: no significant difference for all repair methods Tear size 1-3 cm: no significant difference for all repair methods Tear size 3 cm: lower rate of retear in early ROM groups for single row and transosseous anchors (18.7% vs 28.2%)

15 Kluczynski et al, Analysis 2 Findings Tear size 3-5 cm: no significant difference for all repair methods Tear size >5 cm: higher risk of retear for all methods combined (52.2% vs 22.6%)» Higher retear for double-row anchors (56.5% vs 20%), most massive tears studied used this method

16 So when is early PROM indicated? Smaller tears Tears 3 cm Repair method Transosseous > Double-row > Single-row anchor Supraspinatus repair only Posterior cuff requires greater protection post-op Acute tear followed by early repair Higher probability of developing post-op stiffness Lower risk for retear Younger, non-smoker, non-diabetic, normal cholesterol levels, good tissue quality

17 Rehab Strategies for Different Size Tears No real consensus Some surgeons use one protocol for all types Some use differing protocols with different timelines

18 Rehab Strategies for Different Size Tears Classification Small <1 cm Medium 1-3 cm Large 3-5 cm Massive >5 cm

19 Rehab Strategies for Different Size Tears Small to medium tears ( 3 cm) show lower rate of retear with early mobilization Massive tears (>5 cm) show higher rate of retear with early mobilization Several articles and protocols offer differing approaches for different size tears

20 Ghodadra et al Published 2009 in JOSPT by four orthopedic surgeons and Kevin Wilk, PT Propose two protocols to use for rehab after repair One protocol for small to medium tears ( 3 cm) One protocol for medium to large tears (3-5 cm)

21 Protocol Highlights Small to Medium Tears Medium to Large Tears Abduction Brace First 2 weeks, then at discretion of MD/PT First 2 weeks, then at discretion of MD/PT Submaximal Isometrics Begin on day 4 Begin on day 4 PROM ER/IR in scaption (45-50 by week 3) Full PROM by week 4 Scapular Stabilization Start prone rowing/extension and thera-band ER/IR at week 4 May start sidelying ER strengthening at week 4 AROM Initiate active flexion and abduction to 90 at week 5 Full AROM by week 8-10 Return to Sport Interval Golf at week 15 Tennis at week 24 Swimming at week 26 ER/IR in scaption (30-45 by week 4) Full PROM by week 4-6 Start prone rowing/extension and thera-band ER/IR at week 4 May start sidelying ER strengthening at week 4 Scapular plane flexion in sidelying at week 6 Abduction at week 8 if good mechanics Full AROM by week 8-10 Interval Golf at week 16 Tennis at week 26 Swimming at week 26-29

22 Protocols Classified by Tear Size Type I ( 1 cm) Type II (1-5 cm) Type III (>5 cm) Sling/Abduction Brace Sling for 7-10 days Sling or abductor brace for days Sling or abductor brace for 4 weeks Submaximal Isometrics Begin immediately post-op Begin immediately post-op Begin immediately post-op PROM ER/IR in scaption (45-55 by day 10) Scapular Stabilization Start prone rowing and thera-band ER/IR at week 2 May start sidelying ER strengthening at week 3-4 ER/IR in scaption (35-45 by day 10) Start prone rowing and theraband ER/IR at week 3-4 May start sidelying ER strengthening at week 5-6 ER/IR in scaption (35 by day 10) Start prone rowing and theraband ER/IR at week 3-4 May start sidelying ER strengthening at week 5-6 AROM Full AROM by week 5 Initiate AROM at week 5-6 Initiate AROM at week 5-6 Return to Sport Interval Golf at week 10 Tennis at week 12 Swimming at week 12 Interval Golf at week 15 Tennis at week 20 Swimming at week 20 Interval Golf at week 26 Tennis at week 26 Swimming at week 26

23 Exercise Selection Goals of post-op rehabilitation Protect integrity of repair Minimize pain and inflammation Restore range of motion Restore strength and stability of shoulder Return to activity Gradually increase stress to healing rotator cuff to maximize ROM, strength, and function

24 Exercise Selection Thigpen et al (2016) A.S.S.E.T. consensus statement on rehabilitation following arthroscopic repair Four phase protocol, based on average strength of the repair as a percentage of normal Uses EMG activity level of supraspinatus to choose appropriate exercises

25 A.S.S.E.T. Rehabilitation Guidelines Phase I (post-op weeks 1-6) PROM Repair strength 19-30% at 6 weeks EMG activity level 15% Exercises protected PROM in scapular plane/er at 0 abduction, pendulum, self-assisted scaption, self-assisted ER/IR with wand

26 A.S.S.E.T. Rehabilitation Guidelines Phase II (post-op weeks 6-12) Increased PROM, AAROM, and AROM Repair strength 19-30% at 6 weeks, 29-50% at 12 weeks EMG activity level 15% Exercises pulley, table slides, active/active-assisted supine punches, sidelying active flexion, aquatic AROM

27 A.S.S.E.T. Rehabilitation Guidelines Phase II-III (post-op weeks 8-16) AROM and PRE s EMG activity level 16-29% Exercises ball roll on wall, upright wall slide, progressive upright flexion (maximum 2 lbs), sidelying ER at 25% MVIC, thera-band ER, IR, forward punch

28 A.S.S.E.T. Rehabilitation Guidelines Phase III-IV (post-op weeks 12-20) Endurance EMG activity level 30-49% Exercises scapular rows at various angles, standing ER with dumbbell, thera-band shoulder flexion, thera-band IR at 90

29 A.S.S.E.T. Rehabilitation Guidelines Phase IV (post-op weeks 20+) Advanced strengthening EMG activity level 50% Exercises standing flexion 3-4 lbs, sidelying dumbbell ER, prone horizontal abduction, 90/90 dumbbell ER, seated military press

30 A.S.S.E.T. Rehabilitation Guidelines Guidelines meant to be a starting point for post-op rehab Communication between patient, PT, and surgeon also critical in guiding course of rehab Important to know size of tear and tissue quality Recommend 1-2 visits per week in Phases I and II, 2 visits per week in Phases III and IV

31 When is enough therapy enough? Discharge planning Maximize ROM Adequate functional activity Insurance limitations Prior activity level» Further strengthening needed for athletes, manual laborers, others» Competent to continue independent strengthening program

32 Don t be like Chad Bradford.

ROTATOR CUFF REPAIR REHAB PROTOCOL

Jayesh K. Patel, M.D. Trinity Clinic Orthopaedic and Sports Medicine 1327 Troup Hwy Tyler, TX 75701 (903) 510-8840 ROTATOR CUFF REPAIR REHAB PROTOCOL This rehabilitation protocol has been developed for