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Whats New in Surgery and Rehabilitation of the Rotator Cuff Repair

in 2012?

Friday, February 10, 2012
10:30-12:30 AM





























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Rotator Cuff Repair Surgery: The Surgeons Perspective

Geoffrey Van Thiel, MD
Rush University Medical Center - Chicago, IL
Department of Orthopaedic Surgery


No handouts provided by speaker





































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Rehabilitation Following Rotator Cuff Repair Surgery

Kevin E. Wilk, DPT
Champion Sports Medicine
Birmingham, AL



I. INTRODUCTION

A. The Post-Operative Rehabilitation Overview
1. Rehabilitation programs have changed:
a. Trend toward slower rehab program
b. Why ???
1) Concerns with cuff failures
2) Unique healing concerns
3) Persistent shoulder pain & dysfunction
c. Where are we today?
1) Survey of experienced physical therapist

2. Arthroscopic repairs
a. Increasing among Orthopaedic Surgeons
b. Gradual increase in numbers
c. Patients experience less pain & less stiffness
d. Special concerns for this type of patient because less pain

3. Rehabilitation program must allow for tissue healing constraints

4. Keys to successful rehab in rotator cuff repaired shoulder
a. Promote & Allow Healing - protection
b. establish passive range of motion
c. restore ER muscular strength
d. establish shoulder balance
e. improve scapular position & posture
f. gradually increase applied loads
g. caution against over-aggressive activities - early
h. control applied forces for first 6 months
i. gradual return to functional activities

2. The rehabilitation formula following rotator cuff repair
a. Restore passive motion
b. Control active motion for 2 weeks up to 8 weeks


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c. Allow soft tissue healing then progress to active motion
d. Allow strengthening exercises at 8 to 12 weeeks
II. FACTORS INFLUENCING THE REHABILITATION PROGRAM

A. 11 Critical Factors to Consider Before Initiating the Program
1. Type of repair
a. Arthroscopic technique
b. Deltoid split (mini-open)
c. Deltoid take down (open)

2. Fixation Method:
a. suture anchors
b. single row vs. double row
c. suture bridge technique
Park et al: AJSM 08
Waltrip et al : AJSM 03
d. diamondback repair
Burkhart et al : Arthroscopy 2011

3. Tissue quality
a. Soft tissue integrity
b. Osseous integrity

4. Size of tear & Type of tear
a. Absolute size
b. Number of tendons/muscles involved
c. Crescent, U shaped, L shaped, retracted, etc
Small < 1 cm
Medium 1-3 cm
Large 3-5 cm
Massive > 5 cm

5. Location of tear
a. Which musculotendinous structures are involved
1) Isolated supraspinatus
2) Supraspinatus and infraspinatus
3) Subscapularis
4) Etc.
Burkhart SS: Clin Orthop 92

6. Surrounding tissue quality
a. Integrity of infraspinatus, teres minor and subscapularis
b. Important for force couples



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7. Mechanism of failure (onset)
a. Traumatic (approx. 3-5%)
b. Gradual and progressive failure
8. Patients variables:
a. Activities (work, sports)
b. Motivation
c. Workers compensation
Hawkins: JBJS 85
d. Healing potential
Smokers vs Non-Smokers

9. Rehabilitation potential
a. Supervised rehabilitation
b. Unsupervised rehabilitation

10. Physicians philosophical approach

Conservative Cautiously Aggressive

11. Concomitant Procedures
a. Decompression
b. SLAP repair
c. Capsular procedure

B. Classification of Rotator Cuff Tears
Small < 1 cm
Medium 1-3 cm
Large 3-5 cm
Massive > 5 cm

C. Seven Types of Rehabilitation Programs
Type I - Small Tear (Excellent Tissue)

Type II - Medium to Large Tear (Good Tissue)

Type III - Large to Massive Tear (Poor Tissue)

Type I Arthroscopic Repairs small to medium

Type II Arthroscopic Repairs medium to large

Type III Arthroscopic Repairs large to massive size




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Arthroscopic Repair in Overhead Athlete depends on size & quality

The Rehabilitation Program Must Match the Surgical Procedure
Physician Therapist communication is vital for successful outcome!

III. REHABILITATION FOLLOWING ARTHROSCOPIC ROTATOR CUFF REPAIR

Example: Arthroscopic Repair Type II

Areas to Discuss:
1) Protection
2) ROM
3) Muscle training
4) Functional activities

A. Protection Guidelines:
1. Protection to repair site
2. Promote tissue healing takes a long time to heal
3. To Abduction or Not to Abduct ??
4. Abduction to 30 -45 degrees decreases supraspinatus strain
Hatakeyama et al: AJSM 01
5. Less strain in scapular plane &/or coronal plane
Hatakeyama et al: AJSM 01
6. Effect of abduction on footprint contact
Park et al: AJSM 09

How Long in the Sling:
Fast Rehab Slow Rehab
4 weeks 6-8 weeks

B. ROM Guidelines
1. Immediate Shoulder PROM BUT limited ROM

2. Sling 14-21 days

3. Elbow/hand ROM and gripping exercises

4. PROM for 2-4 weeks

5. Passive ROM can create STRAIN on rotator cuff
Park, et al: AJSM 07
Park, et al: AJSM08

6. Full PROM at weeks 2-4


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7. AAROM L-bar ROM ER/IR days 7-10

8. AAROM L-bar ROM flex week 3-4 (with arm support)

9. PROM is limited & restricted

10. Our PROM guidelines:
ER/IR @ 30/45 deg abduction scapular plane limited ROM
Then progress to ER/IR @ 90 deg abduction scapular plane
Then progress to ER/IR @ 0 deg abduction ( weeks later)

11. Which exercises are Passive ROM
CPM
PROM by Physical Therapist
Dockery et al: Orthop 98

C. Muscle Training Guidelines
1. Isometrics submaximal and sub-painful
Use of Electrical muscle stimulation to rotator cuff
Reinold, Macrina, Wilk: AJSM 08
Emphasize: ER, IR and Scapular Muscles
2. Rhythmic stabs ER/IR week 2
3. Rhythmic stabs flex/ext week 3
4. Scapular strengthening weeks 3-4
5. Active ROM flexion and abduction
6. Use of EMS to shoulder musculature
a. ER/IR ratio: at least 52%
b. Time from surgery

**Factors which determine rate of progression

D. Functional Activity Guidelines
1. Sports activities interval sport programs
a. Golf weeks 14-16
b. Tennis weeks 26 (at least)
c. Swimming week 26 (at least)
d. Weight lifting activities
- May begin at 4-5 months close to body than away from body

E. Long Term Exercises Program
1. Fundamental shoulder exercise program

2. Control heavy lifting for 6-9 mos.


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3. No lifting overhead for 6-9




VI. FUNCTIONAL OUTCOMES

A. Shoulder Strength Following Rotator Cuff Repair Surgery
Rokito et al: JSES 96
1. 42 consecutive patients
2. Isokinetic testing every 3 months for one year
3. Recover of strength correlated with size of the tear
4. Greatest improvement occurred in first 6 months (80%)
5. Slowest muscular group to regain strength, ER!

B. Evaluation of the Shoulder Functionally
1. Rate comfort (pain)
2. Satisfaction level
3. AROM/PROM
4. Functional abilities
Harryman et al: JBJS 91

C. Success vs. Failure
1. What determines outcome?
a. Integrity of repair?
b. Re-establishing dynamic stability
Harryman et al: JBJS 91

Patients 5 years following surgery, approximately 48% recurrent deficit however 87% with
recurrent defect satisfactory outcome.

D. Wilk et al: Tech Shoulder and Elbow Surg 00
1. 22 patients, mini-open repair
2. Average follow-up 40 months
3. Average age 64.7 years (40-76)
4. Size of tears: 1, 9, 8, 4

5. Results:
a) 73% excellent
b) 22% good
c) 4% fair
6. Average score (ASES)
a) Pre-op: 30.7


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b) Postop: 92.0






VIII. SUMMARY

A. Key Points
1. Rehabilitation must be based on type of surgery, tissue quality, and size
of tear
2. Communication is vital
Physician therapist
3. Gradual restoration of motion
4. Re-establish dynamic stability
a. Emphasize muscular balance (ER/IR ratio)
b. Do not exercise through shoulder shrug sign
c. Scapular strength
5. Muscular balance (ER/IR ratio)
6. Watch out for empty can - may be painful if -
7. Do not overload healing tissue
8. Gradual restoration of function

Keys to successful rehab in rotator cuff repaired shoulder
a. Establish passive range of motion
b. Restore ER muscular strength
c. Establish shoulder balance
d. Improve scapular position & posture
e. Control applied forces for first 6 months
f. Gradual return to functional activities




References:

1. Park MC, Idjadi JA, Elattrache NS, Tibone JE, McGarry MH, Lee TQ. The effect of dynamic external rotation comparing 2 footprint-restoring
rotator cuff repair techniques. Am J Sports Med. May 2008;36(5):893-900
2. Parsons BO, Gruson KI, Chen DD, et al: Does slower rehabilitation after arthroscopic rotator cuff repair lead to long term stiffness? J Shoulder
Elbow Surg 19(7): 1034-1039, 2010.
3. Duquin TR, Buyea C, Bisson LJ: Which method of rotator cuff repair leads to highest rate of structural healing? A systematic review. Am J
Sports Med 38(4): 835-841, 2010.
4. Waltrip RL, Zheng N, Dugas JR, Andrews JR. Rotator cuff repair. A biomechanical comparison of three techniques. Am J Sports Med. Jul-Aug
2003;31(4):493-497.
5. Burkhart SS: Fluroscopic comparison of kinematic patterns in massive rotator cuff tears: Asuspension bridge model. 284:144-152, 1992.
6. Hatakeyama Y, Itoi E, Pradhan RL, Urayama M, Sato K. Effect of arm elevation and rotation on the strain in the repaired rotator cuff tendon. A
cadaveric study. Am J Sports Med. Nov-Dec 2001;29(6):788-794.


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7. Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of single- and double-row repairs in rotator cuff tears.
Am J Sports Med. Jul 2008;36(7):1310-1316.
8. Park MC, Park CJ, Ahmad CS, et al: The biomechanical effects of dynamic external rotation on rotator cuff repair compared to testing with
the humerus fixed. Am J Sports Med 35(11): 1931-1939, 2007.
9. Dockery ML, Wright TW, LaStayo PC. Electromyography of the shoulder: an analysis of passive modes of exercise. Orthopedics. Nov
1998;21(11):1181-1184.
10. Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder
external rotation exercises. J Orthop Sports Phys Ther. Jul 2004;34(7):385-394.
11. Harryman DT, Mack LA, Wang KY, et al: Repairs of the rotator cuff: correlation of functional results with the integrity of the cuff. J Bone Joint
Surg 73(7): 982-989, 1991.
12. Wilk KE, Crockett HS, Andrews JR. Rehabilitation after rotator cuff repair surgery. Tech Shoulder Elbow Surg. 2000;1:128-144.
13. Ghodadra NS, Provencher MT, Verma NN, Wilk KE, Romeo AA: Open, Mini-open and all arthroscopic rotator cuff surgery: indications, &
implications for rehabilitation. J Orthop Sports Phys Ther 39(2): 81-89, 2009.
14. Costouras JG, Porramatikui M, Lie DT, Warner JJ: Reversal of supraspinatus neuropathy following arthroscopic repair of massive
supraspinatus & infraspinatus rotator cuff tears. Arthroscopy 23(11): 1152-1156, 2007.
15. Miller BS, Downie BK, Kohen BB, et al; When do rotator cuff repairs fail? Am J Sports Med 39(10): 2064- 2070, 2011.
16: Uhl TL, Muir TA, Lawson L: EMG assessment of passive, active assisted, & active shoulder rehabilitation exercises. Phys Med Rehabil 2(2):
132-141, 2010.
17. Reinold MM, Marcina LM, Wilk KE, et al: The effects of electrical muscle stimulation on the infraspinatus following rotator cuff repair
surgery. Am J Sports Med 36(12); 2317-2321, 2008.
18. Reinold MM, Wilk KE, Fleisig GS, et al: EMG analysis of the rotator cuff and deltoid muscles during common external rotation exercises: J
orthop Sports Phys Ther 34(7): 385-394, 2004.
19. Dodson CC, Kitay A, Verma NN, et al: The long term outcome of recurrent defects after rotator cuff repair. Am J Sports Med 38(1): 35-39,
2010.
20. Burkhart SS, Esch JC, Jolson RS: The rotator crescent & rotator cable: an anatomic description of the shoulders suspension bridge.
Arthroscopy 9(6): 611-616, 1993.
21. Burkhart SS, Denard PJ, Obopilwe E, Mazzocca AD: Optimizing pressurized contact area in rotator cuff repair: The diamondback repair.
Arthroscopy 2011 (in press)








































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THE ROLE OF THE SCAPULA IN EVALUATION AND TREATMENT OF THE SHOULDER
FOLLOWING ROTATOR CUFF REPAIR

TODD S. ELLENBECKER, DPT, MS, SCS, OCS, CSCS
CLINIC DIRECTOR
PHYSIOTHERAPY ASSOCIATES SCOTTSDALE SPORTS CLINIC
SCOTTSDALE, ARIZONA
NATIONAL DIRECTOR OF CLINICAL RESEARCH
PHYSIOTHERAPY ASSOCIATES EXTON, PA
DIRECTOR OF SPORTS MEDICINE, ATP WORLD TOUR

1) A BIOMECHANICAL ANALYSIS OF SCAPULAR ROTATION DURING ARM ABDUCTION IN THE
SCAPULAR PLANE
BAGG & FORREST, AM J PHYS MED & REHAB, 238-245, 1988
BAGG & FORREST THREE PHASES OF ARM ELEVATION
PHASE I: 0-80
PHASE II: 80-140
PHASE III: 140-170

2) RELATIVE INCREASE IN SCAPULAR CONTRIBUTION IN MIDDLE PHASE OF ELEVATION DUE TO
INCREASE IN MOMENT ARMS OF SCAPULAR ROTATORS
EARLY PHASE OF ELEVATION, UPPER TRAP AND LOWER SERRATUS PROVIDE UPWARD ROTATION
LONGER MOMENT ARM OF LOWER TRAPEZIUS WITH ELEVATION OF 90 DEGREES OR GREATER
LOWER TRAPEZIUS AND SERRATUS ANTERIOR PRIMARY ROTARY FORCE COUPLE DURING ARM
ELEVATION IN THE SECOND PHASE (80-140)



3) SCAPULAR DYSKINESIS
AN OBSERVABLE ALTERATION IN THE POSITION & MOTION OF THE SCAPULA RELATIVE
TO THE THORACIC CAGE
KIBLER, 1991, 1998

4) 3 DIMENSIONAL ROTATION OF THE SCAPULA DURING FUNCTIONAL MOVEMENTS:
AN IN-VIVO STUDY IN HEALTHY VOLUNTEERS
BOURNE ET AL, J SHOULDER ELBOW SURGERY16:150-162, 2007

4) KIBLER CLASSIFICATION OF SCAPULAR DYSFUNCTION
TYPE I: INFERIOR ANGLE DYSFUNCTION


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TYPE II MEDIAL BORDER DYSFUNCTION
TYPE III: SUPERIOR DYSFUNCTION
TYPE IV: NORMAL


5) EMG ANALYSIS OF THE SCAPULAR MUSCLES DURING A SHOULDER REHABILITATION
PROGRAM
MOSELEY ET AL, AM J SPORTS MEDICINE 20(2):128-134, 1992
IN-DWELLING EMG 8 SCAPULAR MUSCLES
4 EXERCISES IDENTIFIED:

CORE SCAPULAR PROGRAM

SCAPTION
PUSH-UP W/ A PLUS
ROWING
PRESS-UP

7) CURRENT CONCEPTS IN SHOULDER REHABILITATION
KIBLER WB, ET AL, ADVANCES IN OPERATIVE ORTHOPAEDICS 3:1995
EMG UPPER EXTREMITY CLOSED CHAIN EXERCISE
SHOULDER MUSCULATURE ACTIVATION DURING UPPER EXTREMITY WEIGHT BEARING
EXERCISE

8) UHL ET AL, JOSPT 33(3):109-117, 2003
PROGRESSIVE INCREASES IN EMG ACTIVITY WITH INCREASES IN EXTREMITY LOADING



References
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an in-vivo study in healthy volunteers. J Shoulder Elbow Surg. 2007;16:150-162.
2. Fleisig GS, Barrentine SW, Zheng N, Escamilla RF, Andrews J. Kinematic and kinetic comparison of baseball pitching among various
levels of development. J Biomech. 1999;32:1371-1375.
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study. J Shoulder Elbow Surg. 2002;11:550-556.
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2009;44:160-164.
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2005;33:263-271.
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2009;44:165-173.
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