REHABILITATION & RETURN TO SPORT FOLLOWING GLENOHUMERAL - PowerPoint PPT Presentation

REHABILITATION & RETURN TO SPORT FOLLOWING GLENOHUMERAL ARTHROPLASTY Todd S. Ellenbecker, DPT, MS, PT, SCS, OCS, CSCS Clinic Director & Director of Clinical Research Select Physical Therapy Scottsdale Sports Clinic Vice President, Medical Services ATP World Tour

“DISLOCATION ARTHROPATHY” • INCREASED INCIDENCE OF GLENOHUMERAL ARTHRITIS IN PATIENTS FOLLOWING STABILIZATION PROCEDURES 12-62% • INCIDENCE HIGHER WITH POSTERIOR INSTABILITY THAN ANTERIOR • HIGHER IN OLDER PATIENTS FOLLOWING DISLOCATION • MATSEN – CAPSULORRAPHY ARTHOPATHY

CHARACTERISTICS OF PATIENTS WITH GH JOINT OA • 70 PATIENTS • MEAN AGE 46.1 YRS • PRE-OP EVALUATION • AROM: 105 FF, 95 ABD 45 ER@90, 18 IR@90 • STRENGTH DEFICITS – 37% ER, 30 % IR ER/IR 53% • SHOULDER RATING – SST 4.2, SANE 34

SEVERE OSTEOARTHRITIS OF THE ATHLETIC SHOULDER

GLENOID EROSION

DEVELOPMENT OF A POST- OPERATIVE PROTOCOL:

MARC SAFRAN, MD

REHABILITATION FOLLOWING SHOULDER ARTHROPLASTY • WEEKS (1-6) POST-OP – MODALITIES – PROM / AAROM • No limitations in flexion, abduction or internal rotation – DISTAL UE AROM/PROM – MANUAL SCAPULAR PROTRACTION/RETRACTION RESISTANCE – SUBMAXIMAL RTC (ER) STRENGTHENING

REHABILITATION FOLLOWING SHOULDER ARTHROPLASTY • KEY INITIAL REHAB CONCEPTS (WEEKS 1-6) • SUBSCAPULARIS PRECAUTIONS: – LIMIT EXTERNAL ROTATION ROM – NO ER ROM BEYOND 30-45 DEGREES – NO INTERNAL ROTATION RESISTIVE EXERCISE

EVOLUTION OF POST- OPERATIVE PROTOCOL: ER ROM • NO ER BEYOND NEUTRAL – GREATER ER ROM LOSS IN YOUNGER ACTIVE PATIENTS • NO ER BEYOND 30-45 DEGREES • NO APPLICATION OF OVERPRESSURE IN ER

INITIATION OF ER ROM FOLLOWING SHOULDER ARTHROPLASTY • Caplan et al, JSES 2009 – PROM ER to 15 degrees 4 Wks, then no limitation ER – Result: ER @ side – 35 deg. ER in ABD – 74 deg. • Miller & Flatow, JSES 2003 – PROM ER to 30-40 degrees – Result: ER @ side 60 deg. • Gerber et al, JBJS 2005 – PROM ER to Neutral 6 Wks

BICEP STATUS • BICEP TENODESIS COMMONLY PERFORMED DURING SHOULDER ARTHROPLASTY – NO RESISTED ELBOW FLEXION IN FIRST 6 WEEKS OF REHAB

REHABILITATION FOLLOWING ARTHROPLASTY • MANAGEMENT OF CONCOMMITANT GLENOID OSTEOARTHRITIS • MENISCAL ALLOGRAFT OR GRAFT JACKET – MINIMIZE USE OF EARLY ACCESSORY MOBILIZATION – MINIMIZE GLENOID SHEAR

INITIAL GOAL CAPSULE • ADDRESS CAPSULAR RESTRICTION TO PREVENT OBLIGATE TRANSLATION EFFECTS • CANNOT STRESS ANTERIOR CAPSULE EARLY DUE TO SURGICAL REPAIR

REHABILITATION FOLLOWING HEMIARTHROPLASTY • POST-OP WEEKS (2-4) – INITIATION OF PULLEY AND AAROM FOR SAGITAL AND SCAPULAR PLANE • POST-OP WEEKS (3-6) – INITIATION OF SUBMAX ISOMETRIC AND ISOTONIC RTC EX (NO IR) – UBE – ER STRENGTHEING - (IN ADDUCTION, LIMIT ER TO JUST BEYOND NEUTRAL)

REHABILITATION FOLLOWING SHOULDER ARTHROPLASTY • POST-OP (6-12) – INITIATION OF ER ROM BEYOND 30-45 DEG. – INITIATION OF IR RESISTIVE EXERCISE – TRADITIONAL ISOTONIC ROTATOR CUFF PROGRAM – BICEP/TRICEP RESISTANCE – OSCILLATION/RHYTHMIC STAB • ENDURANCE EMPHASIS

INITIAL GOALS - STRENGTH • MUSCULAR BALANCE • ER/IR IMBALANCE COMMON • ADDRESS NET ER/IR BALANCE

CONSEQUENCES OF INADEQUATE MUSCULAR BALANCE FOLLOWING SHOULDER ARTHROPLASTY

REHABILITATION FOLLOWING SHOULDER ARTHROPLASTY • POST-OP WEEKS 12-24 – ASSESSMENT OF IR/ER STRENGTH (ISOMETRIC) IN NEUTRAL POSITION - BIODEX – ROM ASSESSMENT – SHOULDER RATING SCALES • CONTINUATION OF REHAB – UE PLYO PLYO & 90 / 90 EXERCISE – ISOKINETIC IR/ER (MOD BASE)

RETURN TO SPORT FOLLOWING SHOULDER ARTHROPLASTY • ASES RECOMMENDATIONS – WHAT SPORTS SHOULD BE CONSIDERED ? • OUTCOMES RESEARCH • OBJECTIVE CRITERION FOR RETURN TO SPORT PROGRESSION

A DESCRIPTIVE PROFILE OF GLENOHUMERAL JOINT RANGE OF MOTION AND STRENGTH FOLLOWING COPELAND HEMIARTHROPLASTY ELLENBECKER TS & BAILIE DS

HUMERAL RESURFACING ARTHROPLASTY • 43 CONSECUTIVE PATIENTS • MEAN AGE – 45.7 YEARS • PROM @ 2 & 6 WKS, AROM 12 WEEKS • ISOMETRIC IR/ER MODIFIED BASE • SHOULDER RATING SCALES • AVE. - 9.6 VISITS FIRST 6 WEEKS P/O • AVE – 11.4 VISITS B/T 6 & 12 WKS P/O

ROM S/P HUMERAL RESURFACING ARTHROPLASTY MOTION 12 WEEKS 12 WEEKS PROM (S) AROM FLEXION 156 120 ABD 142 108 EXT. ROT. 69 90 AB INT. ROT. 38 90 AB

ISOMETRIC STRENGTH S/P HUMERAL RESURFACING 12 WEEKS POST-OP • ER DEFICIT: 41% • IR DEFICIT: 40% • ER/IR RATIO 56 (I) 57 (UI) • SST: 6.67/12

• Review of literature on return to sports after Shoulder Arthoplasty

Liu et al, JSES 2016

CEMENTLESS HUMERAL RESURFACING ARTHROPLASTY IN ACTIVE PATIENTS LESS THAN 55 YEARS OF AGE BAILIE DS, LLINAS P, ELLENBEKCER TS JBJS 90-A(1):110-117 2008

HUMERAL RESURFACING • COPELAND HUMERAL RESURFACING • 36 PTS, MEAN AGE 42.3 YRS • REHABILTATION PROTOCOL • 2 YEAR FOLLOW-UP

BAILIE ET AL, 2008 SCORE PRE-OP POST-OP VAS 7.5 1.3 SANE SCORE 24.7 90.4 ASES 29.8 87.7

SUMMARY • SHOULDER ARTHROPLASTY CAN PROVIDE HIGH LEVEL FUNCTIONAL RETURN • INCREASED INCIDENCE OF OSTEOARTHRITIS IN YOUNG ACTIVE INDIVIDUALS • PROGRESSIVE REHABILITATION PROGRAM AND OUTCOMES TESTING ASSISTS IN RETURN OF FUNCTION FOLLOWING SURGICAL PROCEDURE

FUTURE DIRECTIONS

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