Rehabilitation of rotator cuff tears: A literature review and evidence-based rehabilitation protocol Prof drann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy Ghent University, Belgium Epidemiology (Simon Lambert, EUSSER conference London 2012) 1
Classification of RC tears (Al-Hakim S&E 2015) Normal rotator cuff Classification of RC tears (Al-Hakim S&E 2015) Common tear of the ageing cuff Remains stable because the fibrous endoskeleton remains attached Often acceptable restoration of function and pain after initial onset 2
Classification of RC tears (Al-Hakim S&E 2015) The predominantly unstable cuff lesion Cable is slack and retracts medially Rotator interval widens allowing humeral head escaping anterosuperiorly Classification of RC tears (Al-Hakim S&E 2015) The predominantly weak cuff lesion Tear extends posteriorly, through the posterior pillar Weak external rotation Slight posterio-superior subacromial shift 3
Classification of RC tears (Al-Hakim S&E 2015) Massive rotator cuff tear All 3 muscles involved Unstable, weak and painful Often lesion LHB, synovitis, joint arthropathy How active are the elderly? Master Athletes = Active individuals aged 50yrs or older, who desire optimal levels of performance or wish to exercise for general health and have high expectations for sports medicine care, including return to sport or activity after injury (Selected Issues for the Master Athlete and the Team Physician: A consensus statement. Med Sci Sports Exc 2010) 4
Exercise as a treatment for RC full thickness ruptures (Systematic Review Ainsworth & Lewis, BJSM 2007) Exercise therapy, defined as strengthening and stretching, when included as a part of a treatment program, has a beneficial effect for patients who have symptomatic shoulders and radiological or arthroscopic evidence of full thickness RC tears Not possible to determine if exercise alone or combined with other interventions offer the greatest benefit Time-recommendations: 3-18 months Exercise as a treatment for RC full thickness ruptures (Kuhn MOON study JSES 2013) Large multi-center Case Series study (N=452) Conservative treatment following specific protocol Follow-up 6-12 weeks with 3 options: (1) cured, (2) better, continue program, and (3) no better, offered surgery Final follow up 1-2 year Sign improvement of patient-reported outcomes 75% successful, <25% go to surgery Cut off point for success/failure +/- 12 weeks 5
Exercise as a treatment for RC full thickness ruptures (Kukkonen Bone Joint J 2015) RCT: (1) physiotherapy, (2) acromioplasty + physiotherapy, (3) RC repair, acromioplasty + physiotherapy No group differences at final follow-up 12 months General Guidelines for rehabilitation Capsular mobilization to increase ROM Stretching after capsular mobilization Maximize RC strength Maximize scapular position/motion as part of the scapulohumeral rhythm Change workouts: lighter weights, different positions. (Selected Issues for the Master Athlete and the Team Physician: A consensus statement. Med Sci Sports Exc 2010) 6
Personal Experience Patients often have deficient rotator cuff: value of cuff training? Let s try to optimize function without focussing too much on the structures Re-education of daily and athletic activities with the purpose to postpone the final match Conservative treatment RC tears (partial, irreparable) TREATMENT GOAL optimize function, in particular elevation above shoulder height, with limited load on the RC 7
Scientific base for Treatment Strategy (Uhl PM&R 2010, Levy JSES 2008) EMG in SS < 10% MVC 8
Semi-closed chain exercises without/with resistance (1) 9
Semi-closed chain exercises without/with resistance (2) Semi-closed chain exercises without/with resistance (3) 10
3 stages of exercises: 1. Passive 2. Active 3. With resistance and increase inclination (Levy et al. JSES 2008) 11
(Levy et al. JSES 2008) 12
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POSTOPERATIVE TREATMENT after RC repair Factors affecting the postoperative rotator cuff healing and rehabilitation program: 1. Demographic factors (younger age, male) 2. Clinical factors (no diabetes, no obesity, no smoking, more sports activity and ROM pre-op) 3. Factors related to cuff integrity (size of the tear, less fatty infiltration and retraction) 4. Factors related to surgical procedure (no concomitant biceps of AC procedures) (Fermont et al. Prognostic factors for successful recovery after arthroscopic rotator cuff repari: a systematis literature review JOSPT 2014;44(3):153-163) GOALS of the rehabilitation Protect the repair Promote healing Gradually restore ROM Gradually restore muscle strength Gradually restore function 14
Protect the repair Soft tissue-to-bone healing is slow: starts with formation of fibrovascular tissue interface between tendon & bone (Rodeo JBJS 1993) At least 12 weeks of healing is necessary allowing pull-out strength of the repair (Sonnabend JBJS 2010) Factors that improve tendon-to-bone healing: Pressure (Weiler Arthr 2002) Tendon immobilisation (Ghodadra JOSPT 2009) Positioning (abduction / scapular plane) (Hatakeyama AJSM 2001) (Ghodadra NS et al. Open, Mini-open and all-arthorscopic rotator cuff repair surgery: indications and implications for rehabilitation JOSPT 2009) 15
Immobilisation: Risk for frozen shoulder incidence of 5% stiff shoulder after RC repair, with risk factors: <50y, workers compensation insurance (Huberty Arthr 2009) + important risk factor is pre-operative stiffness (Evans Bone Joint 2015) Sling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in increased long-term stiffness and may improve the rate of tendon healing. (Parsons JSES 2010) Early mobilisation: Risk for re-tear Strong evidence that early initiation of rehabilitation and functional loading does not adversely affect clinical outcome (Syst Review Littlewood S&E 2015) Early ROM exercises accelerate recovery, but are likely to result in improper tendon healing in shoulders with largesized tears (meta-analysis of RCT Chang AJSM 2014) Pooled OR for retear in early rehab group is 1,3 (0,72-2,2) (Syst Review Littlewood S&E 2015) 16
Summary Individualized choice of rehabilitation program based on risk factors (Chang AJSM 2014) In at-risk patients (with calcific tendonitis, adhesive capsulitis, labral repair), a postoperative rehabilitation regimen that incorporates early closed-chain passive overhead motion can reduce the incidence of postoperative stiffness after arthroscopic rotator cuff repair. (Koo Arth 2011) What after surgery? (Schumann et al. AJSM 2010, Bülhoff 2015) 17
What after surgery? (Schumann et al. AJSM 2010, Bülhoff 2015) 18
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Take home message Take care of the degenerative changes in the shoulder, but Remind you often have to deal with an active elderly patient There is still hope after shoulder arthroplasty! (Gent, Belgium) 20