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What’s 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 Surgeon’s 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. Patient’s variables: a. Activities (work, sports) b. Motivation c. Worker’s compensation Hawkins: JBJS ‘85 d. Healing potential Smokers vs Non-Smokers

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

10. Physician’s 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: AJSM’08 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 shoulder’s “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

1. Bourne DA, Choo AM, Regan WD, MacIntyre DL, Oxland TR. Three dimensional rotation of the scapula during functional movements: 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.

3. Forthomme B, Crielaard JM, Croisier JL. Scapular positioning in athlete’s shoulder. Sports Med. 2008;38:369-386. 4. Kibler WB. The role of the scapula in the overhead throwing motion. Contemp Orthop. 1991;22:525-532. 5. Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med. 1998;26:325-337. 6. Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation of scapular dysfunction: a reliability

study. J Shoulder Elbow Surg. 2002;11:550-556. 7. Konda S, Yanai T, Sakurai S. Scapular rotation to attain the peak shoulder external rotation in tennis serve. Med Sci Sports Exerc.

2010;42:1745-1753. 8. Laudner KG, Stanek JM, Meister K. Differences in scapular upward rotation between baseball pitchers and position players. Am J

Sports Med. 2007;35:2091-2095. 9. McClure PW, Michener LA, Sennett BJ, Karduna AR. Direct 3-dimensional measurement of scapular kinematics in vivo. J Shoulder

Elbow Surg. 2001;10:269-277. 10. McClure PW, Tate AR, Kareha S, Irwin D, Zlupkp E. A clinical method for identifying scapular dyskinesis, Part 1: reliability. J Athl Train.

2009;44:160-164. 11. Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Scapular position and orientation in throwing athletes. Am J Sports Med.

2005;33:263-271. 12. Nijs J, Roussel N, Struyf F, Mottram S, Meeusen R. Clinical assessment of scapular positioning in patients with shoulder pain: state of

the art. J Manipulative Physiol Ther. 2007;30:69-75. 13. Oyama S, Myers JB, Wassinger CA, Ricci D, Lephart SM. Asymmetric resting scapular posture in healthy overhead athletes. J Athl Train.

2008;43:565-570. 14. Reid M, Elliott B, Alderson J. Lower-limb coordination and shoulder joint mechanics in the tennis serve. Med Sci Sports Exerc.

2008;40:308-315. 15. Tate AR, McClure P, Kareha S, Irwin D, Barbe MF. A clinical method for identifying scapular dysnkinesis, Part 2: validity. J Athl Train.

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2009;44:165-173. 16. Uhl TL, Kibler WB, Gecewich B, Tripp BL. Evaluation of clinical assessment methods for scapular dyskinesis. Arthroscopy. 2009;25:1240- 1248.