I FIXED THE CUFF BUY MY PATIENT IS STIFF ? WHAT HAPPENED & WHAT - PowerPoint PPT Presentation

I FIXED THE CUFF BUY MY PATIENT IS STIFF ? WHAT HAPPENED & WHAT I NEED FROM THE SURGEON TODD S. ELLENBECKER, DPT, MS, SCS, OCS, CSCS CLINIC DIRECTOR & DIRECTOR OF CLINICAL RESEARCH SELECT PHYSICAL THERAPY SCOTTSDALE SPORTS CLINIC SCOTTSDALE, ARIZONA VICE PRESIDENT, MEDICAL SERVICES ATP WORLD TOUR

WHAT DO WE KNOW ABOUT STIFFNESS FOLLOWING RTC REPAIR ?

• COMPARISON B/T EARLY SURGERY WITH CAPSULAR RELEASE & DELAYED SURGERY WITH PRE-OP PT TO ADDRESS CAPSULAR RESTRICTION • NO SIG DIFFERENCE IN ROM RETURN OR OUTCOME WITH EITHER METHOD…….

• RETROSPECTIVE REVIEW 43 PATIENTS NO ROM FOR 6 WEEKS WITH FULL SLING IMMOBILIZATION • SUBSET OF 10 PATIENTS DEEMED STIFF AT 6-8 WEEKS – FF LESS THAN 100 DEGREES, AND ER LESS THAN 30 (PROM) • AT 1 YEAR – NO SIGNIFICANT DIFFERENCES IN AROM & FUNCTION “SLING IMMOB FOR 6 WEEKS DOES NOT RESULT IN INCREASED LONG TERM STIFFNESS AND MAY IMPROVE TENDON HEALING”

• IDENTIFICATION OF RISK FACTORS WITH RTC REPAIR – CALCIFIC TENDONITIS, PASTA LESION, SLAP REPAIR, ADHESIVE CAPSULITIS & SINGLE TENDON RTC REPAIR • MODIFICATION OF POST-OP PROTOCOL IN PATIENTS WITH RISK FACTORS • 79/152 RTC REPAIRS HAD MODIFIED PROTOCOL • 0/79 PATIENTS HAS POST-OPERATIVE STIFFNESS USING MODIFIED PROTOCOL WITH CLOSED CHAIN OVERHEAD MOVEMENT PATTERN APPLIED • CONCLUSION: IN PATIENTS WITH RISK FACTORS, CLOSED CHAIN OVERHEAD EXERCISE CAN BE EFFECTIVE TO PROVENT POST-OP STIFFNESS

PT: What do I need from the Surgeon ? • Optimal – Prescription • Tear Size (ie Massive) • Tendon(s) involvement • Protocol to follow • Complications – Operative Report – Protocol • Clear definitions of: – PROM – AAROM, – AROM – Resistive Exercise

ELEMENTAL QUESTION: WHAT ARE THE EFFECTS OF EARLY V DELAYED ROM AFTER ROTATOR CUFF REPAIR • EVIDENCE: – BASIC SCIENCE – EFFECT OF FIXATION METHOD AND REPAIR STRENGTH – EFFECT OF SPECIFIC RANGES OF MOTION (ROTATION / PLANE) – CLINICAL OUTCOMES VERSUS LABORATORY OUTCOMES – CLINICAL STRATEGIES TO MINIMIZE TENDON LOADING YET DECREASE RISK OF STIFFNESS

Park et al, 2008 • Loading Based on Rehabilitation Parameters • Passive ER Rom <5% of SS MVIC • Active ER @ side 30% SS MVIC • Max SS contraction 300 N • Post-op Exercise 15- 90 N

POST OPERATIVE ROTATOR CUFF REHABILITATION PROTOCOL: MEDIUM – LARGE TEARS

REHABILITATION FOLLOWING ROTATOR CUFF REPAIR • INITIAL PHASE: (0-4 / 0-6 WEEKS) – MODALITIES – PROM PROGRESSING TO AAROM /AROM – CAUTION WITH ACTIVE ABDUCTION – ROM RESTRICTIONS (?) – SCAPULAR STABILZATION – TAS REHAB

WHAT DOES BASIC SCIENCE RESEARCH TELL US ABOUT SAFE RANGE OF MOTION FOLLOWING ROTATOR CUFF REPAIR ?

EFFECT OF ARM ELEVATION AND ROTATION ON THE STRAIN OF THE REPAIRED ROTATOR CUFF TENDON: A CADAVERIC STUDY HATAKEYAMA & ITOI ET AL, AM J SPORTS MED 29(6):788-794, 2001

EFFECT OF ROTATION ON ROTATOR CUFF TENDONS • 14 CADAVER REPAIRS (2 x 1.5) CM • STRAIN MEASURED IN 30 DEGREES OF ELEVATION IN THE: – SCAPULAR PLANE – CORONAL PLANE – SAGITTAL PLANE

EFFECT OF ROTATION ON ROTATOR CUFF TENDONS • SCAPULAR & CORONAL PLANES : – INCREASED STRAIN IN 30 & 60° OF IR – DECREASED STRAIN IN 30 & 60° OF ER • SAGITTAL PLANE : – INCREASED STRAIN IN ALL POSITIONS RELATIVE TO CORONAL AND SCAPULAR PLANE POSITIONS • CONCLUSION: ER OF UP TO 60° DECREASES STRAIN IN REPAIRED ROTATOR CUFF TENDON IN 30° OF ELEVATION IN EITHER THE SCAPULAR OR CORONAL PLANES

THE EFFECT OF ARM POSITION ON STRETCHING OF THE SUPRASPINATUS, INFRASPINATUS, AND POSTERIOR PORTION OF THE DELTOID MUSCLES: A CADAVERIC STUDY MURAKI ET AL, 2006 CLIN BIOMECHANICS 21:474-480

EFFECT OF X-ARM ADDUCTION ON RTC TENSION / STRETCHING • NO SIGNIFICANT AFFECT OF X-ARM ADDUCTION AT 60 DEGREES ELEVATION ON THE SUPRAPSINATUS, AND INFRASPINATUS • INFRASPINATUS: IR WITH EXTENSION INCREASED STRAIN – IR @ 60 DEGREES ELEVATION AND X-ARM ADDUCTION DID NOT INCREASE STRAIN OVER NEUTRAL POSITION • CONCLUSIONS: – OBJECTIVE QUANTIFICATION OF SPECIFIC RANGES OF MOTION WHICH INCREASE TENSION ON THE RTC – KNOWLEDGE OF TEAR SIZE AND TENDON INVOLVMENT CRUCIAL TO ENSURE SAFE ROM USED IN POST-OP REHABILITATION

MANUAL THERAPY 12 (2007): 231-239

• DECREASED STRESS ON REPAIRED SUPRASPINATUS TENDON WITH 30 DEGREES ABDUCTION WITH GH JOINT MOBILIZATION • SAME STRESS AS RESTING POSITION • CLINICAL APPLICATION:

CODMAN’S EXERCISE: PASSIVE RANGE OF MOTION ? EMG OF SELECTED SHOULDER MUSCULATURE DURING UN-WEIGHTED AND WEIGHTED PENDULUM EXERCISES TYLER ET AL, NAJSPT 2006 1:2(73-79)

NO SIGNIFICANT DIFFERENCE B/T TYPES OF WEIGHTED & UNWEIGHTED CODMANS RTC GROUP HAD GREATER MUSCLE ACTIVATION

• Detrimental effects of paralysis and immobilization • Loss of scar volume and lower ultimate load of repair with no stress applied to repaired tendon

• SMALL TO MEDIUM SIZE TEARS • SLING USE – ABDUCTION SLING/BRACE • GROUP 1 – PROM 3-4 TIMES PER DAY • GROUP 2 – NO PROM FOR 4-5 WEEKS – 4 WEEKS SMALL TEAR – 5 WEEKS MEDIUM TEAR

KIM ET AL, 2012 • RESULTS: – FOLLOW UP AT 3,6,12 WEEKS POST-OP • NO SIG DIFFERENCE B/T GROUPS IN PROM IN ANY PLANE OF MOTION • NO DIFFERENCE IN VAS • @ 12 MOS – NO CHANGE IN CONSTANT OR ASES – DETACHMENT OF RTC REPAIR 12 MOS • 12% GRP 1 • 18% GRP 2 (NO SIG DIFFERENCE) – EARLY PROM DID NOT GUARANTEE ROM RETURN BUT DID NOT NEGATIVELY AFFECT THE REPAIR !!!

RIBOH & GARRIGUES, 2014

RIBOH & GARRIGUES, 2014

CLINICAL APPLICATION: GAINING EXTERNAL ROTATION ROM S/P RTC REPAIR • INCREASED TENSION ON SUPRASPINATUS TENDON WITH ADDUCTED GLENOHUMERAL POSITION

REHABILITATION FOLLOWING ROTATOR CUFF REPAIR • GAINING EXTERNAL ROTATION – ABDUCTION POSITION SEQUENCE • INITIAL ER @ 45° • EARLY PROGRESSION TO ER WITH 80-90 ° ABDUCTION TO ADDRESS ANTERIOR/INFERIOR CAPSULE • ER IN 0° ABDUCTION LAST DUE TO INCREASED STRESS ON SUPRASPINATUS REPAIR

IS THERE A DIFFERENCE BETWEEN ACTIVE & PASSIVE ROM FOLLOWING ROTATOR CUFF REPAIR ?

• ACTIVE RANGE OF MOTION – EARLY < 6 WEEKS POST-OP / DELAYED > 6WEEKS POST-OP • NO SIG DIFFERENCE B/T EARLY & DELAYED AROM IN RE-TEAR RATES: – < 1 CM, 1-3 CM OR 3-5 CM FOR ANY FIXATION METHOD • INCREASED RISK OF RE-TEAR: – < 3 CM ONLY FOR SINGLE ROW REPAIRS – ALL FIXATION GROUPS >3 CM – >5 CM IN EARLY GROUP FOR SB FIXATION

AJSM, 2016

SHORT TERM OUTCOME: EARLY RANGE OF MOTION FOLLOWING ROTATOR CUFF REPAIR

Descriptive Report of Shoulder Range of Motion and Isometric Rotational Strength 6 and 12 Weeks Following Arthroscopic Rotator Cuff Repair • Ellenbecker, TS • LaSueur, D • Sueyashi, T • Bailie DS

Ellenbecker et al, 2016 TABLE 3. Comparison of isometric shoulder internal (IR) and external rotation (ER) strength values of the injured and uninjured extremities measured at 12 weeks (n=60 patients) Position Injured Shoulder Uninjured Shoulder (Mean ± SD) (Mean ± SD) with (%) Difference External Rotation Strength 11 ± 6 16 ± 7 (28.5%) Internal Rotation Strength 20 ± 9 25 ± 10 (17%)

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