Rotator+Cuff+Repair+Interventions

//** Rotator Cuff **//   The should girdle is made up of three different bones: -Humerus -Clavicle -Scapula At the glenohumeral joint the humerus is stabilized by a group of muscles known as the rotator cuff. There are four muscles that make up this structure. You may also hear them in a pneumonic referred to as the SITS muscles. (1)
 * // Anatomy //**


 * S **upraspinatus
 * I **nfraspinatus
 * T **eres Minor
 * S **ubscapularis

This group of muscles is responsible for humeral stabilization and also helps to lift and rotate the arm. These muscles are in control of the joint that has the greatest range of motion in our body. Without proper functioning, our shoulder girdle may become prone to weakness, injury, and loss of function. (1)

http://wavesport.ning.com/profiles/blogs/how-to-recovery-from-a-rotator

Here is an excellent video explaining the anatomy or the rotator cuff and mechanics in the glenohumeral joint. As a physical therapist, it is our job to explain the musculature and anatomy to the patient for their particular injury. We must understand that not everyone one knows that the rotator cuff is made up of multiple muscles and is not just a single “cuff” that stabilizes the shoulder. (1)

media type="youtube" key="SfUmN_V-28w" height="315" width="560"

//** Injury **// Multiple factors play a role in an injury to the rotator cuff. Injuries come from a variety of factors and can be extremely debilitating to the patient. Some examples of these injures include:

Lifting heavy objects Falling on an outstretched arm or hand Other should injuries à Dislocated shoulder Repetitive use to the tendons à Especially overhead activities Athletic injuries Trauma Atrophy/lack of blood supply associated with aging Bone Spurs (1)

The most common injury to the rotator cuff occurs at the supraspinatus tendon.

There are two different types of tears that may occur at the tendon:

1) Partial Thickness Tear: This type of tear damages the soft tissue, but does not completely tear at the tendon

http://www.orthogate.org/patient-education/shoulder/rotator-cuff-tears.html

2) Full Thickness/Rupture: This type of tear is also called a complete tear. It splits the soft tissue into two pieces. In many cases, tendons tear off where they attach to the head of the humerus. With a full-thickness tear, there is basically a hole in the tendon. (1)

http://www.eorthopod.com/content/rotator-cuff-tears

With a full thickness tear to a rotator cuff muscle, surgery may be the best plan of care for a patient. This may require extensive rehabilitation at the hands of a physical therapist. For some injuries that are not as traumatic or are partial tears, surgery may not be indicated. In this case, physical therapy/occupational therapy will still be important to the patient in gaining strength and function. (1)


 * Modalites**


 * Cryotherapy during the first 24 hours post-operatively has been shown to reduce pain, and thereby reduce the use of narcotic medication to manage pain. Cryotherapy has been linked to a higher tolerance to rehabilitation sessions and to better sleep. [18]
 * Continuous Passive Motion (CPM) machines can be used in the first 3-4 weeks post-operatively to manage pain and maintain range of motion in the glenohumeral joint. [18] However, CPMs are very costly and show no long-term benefits when compared to protocols that do not use the CPM and are therefore not supported by the literature. [6]

[]


 * Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended until six weeks post-operatively. In an animal study using rats with torn a torn supraspinatus, NSAIDs were shown to inhibit tendon to bone healing when compared to controls. [11]
 * [[image:kumc-ptrs-ebp/tens.png]]
 * www.tens.com.au


 * Manual Therapy**
 * Glides of the glenohumeral joint are effective in addressing pain, stiffness and limited range of motion. These glides are best done in 30 degrees of abduction in the scapular plane. In the early stages, grades I and II are effective at reducing pain. In the later stages, grades III and IV are effective at increasing ROM and reducing stiffness. [18]
 * Posterior glide to promote shoulder flexion, internal rotation, and horizontal adduction:media type="youtube" key="wt4857NnBoc" height="315" width="560"


 * Anterior glide to promote shoulder extension, external rotation and horizontal abduction:media type="youtube" key="8Ce4Zxus1Lo" height="315" width="560"


 * Lateral distraction for general mobility:media type="youtube" key="q7SxYCMAgB4" height="315" width="420"


 * Conservative Management for a Rotator Cuff Injury**

Conservative treatment is usually the first option for rotator cuff injuries. This may include rest, NSAIDs, glucocorticoid injections and/or physical therapy. If there is no reduction in pain symptoms and improvement in function after 3-6 months, surgery may be indicated (8). Conservative treatment is appropriate for less active people (usually those older than 60) who’s rotator cuff tear does not cause pain, significant weakness or sleep problems. Things to think about with this population though, are the complications that can occur along with conservative treatment. These include progressive arthritis, pain and significant loss of strength, flexibility and function. If these become a problem, arthroscopic debridement and smoothing procedures can be done to restore enough function without having to repair the rotator cuff (7).


 * Surgical Management for a Rotator Cuff Injury**

Indication for Rotator Cuff Surgery Surgery can involve several different aspects including acromioplasty, subacromial bursectomy, removal of calcific deposits and debridement. These together are grouped under the surgical term “decompression”. These are done in order to make room for the rotator cuff tendon so that it is not pinched or irritated and to remove any tissue that will prevent healing (8). A rotator cuff “repair” involves repairing a damaged rotator cuff tendon, usually with stitches. If a significant partial or full thickness tear is present in the tendon, then it can be repaired. There are a few ways to perform surgery for a rotator cuff injury, whether it is an arthroscopic surgery or open surgery (8). The goal of a rotator cuff repair is to reattach the tendon back to the bone. Suture anchors are often placed in the bone to help attach the sutures with the bone and tendon. These materials can be made of metal or materials that dissolve over time (don’t need to be removed later) (18).
 * If pain does not improve with nonsurgical methods
 * If you are very active and use your arms for overhead activities
 * Symptoms have lasted 6-12 months
 * Large tear (More than 3 cm)
 * Significant weakness and loss of function in shoulder
 * Tear was due to a recent, acute injury (1)
 * Acromioplasty – removal of a piece of surface of the acromion with surgical instruments in order to reduce friction damage to a tendon.
 * Subacromial bursectomy – removal of the subacromial bursa.
 * Removal of calcific deposits
 * Debridement – removing loose fragments of tendon, bursa, and other debris from the space in the shoulder were the rotator cuff moves (7)

In open surgery, a 2-3 in. incision in the shoulder is made in order to view the shoulder directly during repairing of the rotator cuff. This type of surgery is more invasive than the arthroscopic approach and requires a short stay in the hospital (7). Open surgery is indicated if the tear is large or complex. The deltoid muscle is detached to better see and gain access to the torn tendon. This type of surgery is indicated if reconstruction such as a tendon transfer is required (1).
 * Open repair**

media type="youtube" key="EHUp14sp_wo" height="315" width="560"

A small camera is inserted into the shoulder joint. Surgical instruments are inserted into the surgical area through small incisions and are guided by the camera on a screen the surgeon watches. This is the least invasive surgical method and is usually an outpatient procedure (1). Research has shown that an arthroscopic approach may result in less morbidity and shorter recovery time of the patient, which allows for a quicker return to work and/or sport (8). Advantages of arthroscopic surgery Disadvantages of arthroscopic surgery
 * Arthroscopic repair**
 * Less post-operative pain
 * Less time in hospital
 * Quicker return to work and sports
 * No stitches to remove
 * Less wound complications (2)
 * Requires more technical skills from surgeon
 * Uses different tools than with open surgery

http://orthoinfo.aaos.org/topic.cfm?topic=a00406

http://orthoinfo.aaos.org/topic.cfm?topic=a00406
 * (Left)** An arthroscopic view of a healthy shoulder joint. **(Center)** In this image of a rotator cuff tear, a large tear can be seen between the edge of the rotator cuff tendon and the humeral head. **(Right)** The tendon has been reattached to the humeral head with sutures.

http://www.shoulderdoc.co.uk/article.asp?article=62

media type="youtube" key="Ve_D4_T9ZF8" height="315" width="560"

In mini open repair, a small incision is made (3-5cm). Arthroscopic techniques are used to assess and treat damage to other structures, but the repair of the rotator cuff is done without video monitor viewing. The surgeon will repair the rotator cuff through the mini-open incision (1).
 * Mini open repair**

Anaesthetic, comorbidities, infection, post-operative capsulitis (Frozen shoulder), deltoid atrophy/detachment, chronic pain, failed rotator cuff repair (need for repeated surgery) (8). Other complications include deltoid nerve or blood vessel damage and Complex Regional Pain Syndrome (7).
 * Complications of Surgery**


 * Factors for Decreased Patient Satisfaction Post-surgery**
 * Poor tendon/tissue quality
 * Large or massive tears
 * Poor patient compliance with rehabilitation and restrictions after surgery
 * Patient age (older than 65 years)
 * Smoking and use of other nicotine products
 * Workers’ compensation claims

Discomfort will occur after surgery, but pain medications may be prescribed to decrease this pain. The patient should expect to wear a protected sling or immobilizer for 4-6 weeks. Physical Therapy will start soon after surgery (7).
 * What to Expect after Surgery**

Coughlan et al conducted a review to determine the effectiveness and safety of surgery in the treatment of rotator cuff disease of the shoulder. No firm conclusions could be drawn. Three trials reported no difference in outcome between open or arthroscopic surgery compared with active non-operative treatment for impingement syndrome. When comparing arthroscopic vs. open decompression, there were no significant differences found in outcomes for pain, UCLA score, participant evaluation of success, or adverse events post-op. Shoulder ROM was also found to show no significant differences, except in two trials in which the arthroscopic group showed earlier improvements. Two trials reported shorter operation time and four trials reported a quicker recovery with arthroscopic decompression. This may be due to preserving the deltoid with this approach. There are two benefits for arthroscopic surgery in comparison to open surgery. In arthroscopic surgery, the incisions are smaller, leaving smaller scars and also during this surgery, there is access to the glenohumeral joint in order to rule out other shoulder issues (8). There is little evidence to support or refute the effectiveness of surgery for rotator cuff disease. The decision to choose surgery is largely based on patient preference, failure of conservative treatment or a combination of both. Selection of specific types of surgery is dependent on the surgeon and their training (8).
 * Efficacy of Surgery**

The rehabilitation should begin immediately after surgery with great communication between the surgeon, the physical therapist, and the patient. The extent of the tear, structures involved, and what steps were taken to repair the rotator cuff should be topics of conversation from the start of therapy. Rehabilitation guidelines should also be discussed at this time, and continuously be re-evaluated and modified as treatments progress. Restrictions and precautions need to be made 100% clear to the patient, and then a protocol for therapy should be established based on the patient profile. (18) There are typically two approaches as far as protocol is concerned: a conservative approach usually used on geriatric patients or patients with larger tears and poor quality of tissues. The conservative protocol consists of a delayed initiation of PROM and/or a complete restriction of PROM for 2-4 weeks. The moderate approach takes a completely different approach by initiating PROM on post-op day one, assuming tolerable pain levels. (18) The RCR rehab is usually broken into 5 stages. Phase 1 consists mostly of protecting the repaired structures with some light PROM. Phase 2 starts when the patient is cleared to begin AAROM, and consists of AAROM activities with progression into small amounts of slow AROM and sub-max isometrics. Phase 3 starts when the patient is able to start initial strengthening with closed chain stabilization and isotonic exercises. In the late stage of phase 3 into the beginning of phase 4 is when we think of entering the “chronic” stage. Phase 4 begins when the patient can move forward into “advanced” strengthening. Phase 5 is characterized as return to sport/activity. (18)
 * __Acute Phase of Rehab:__**


 * Phase 1 (1-4 weeks)**: Following surgery, the patient is instructed to not move their shoulder at all, leaving it in the sling in order to let the muscles and tendons heal properly. “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” (14). Therapeutic exercises include:
 * 1) Wrist/Elbow ROM[[image:kumc-ptrs-ebp/shoulderpendulum..gif align="right"]]
 * 2) Grip exercises
 * 3) Pendulums – supported initially


 * 1) PROM
 * 2) Elevation ~ 140 deg
 * 3) ER to 40 deg @ 0, 45, and 90 deg abduction
 * 4) IR of 40 deg with thumb to L1
 * 5) Later in therapy, patients able to do their own passive stretches with a table/countertop
 * 6) NO ACTIVE ROM
 * 7) Aquatic therapy starting around 2 weeks

Therapeutic exercises: This is usually when patients are given a HEP with stretching in all directions, active exercises according to their progress, and cryotherapy. (14)
 * Phase 2 (4-8 weeks):** Sling wear is discouraged and patient expected to wean off of sling and abduction pillow.
 * 1) PROM to full ROM in all directions
 * 2) AAROM –
 * 3) Supine using a t-bar/cane/other limb to aid à progress to standing
 * 4) D1/D2 PNF progressing to active supine
 * 5) Log rolling with assist from other limb
 * 6) Initial strengthening
 * 7) Minimal resistance isometrics for ER/IR at 0, 45, and 90 deg abduction (Pressure applied by therapist while supporting arm)
 * 8) Scapular exercises (retraction/protraction)
 * 9) ER in side lying

Therapeutic exercise: i. Prone rows ii. Elevation iii. Serratus Punches iv. Side lying ER v. ER, IR, and extension using theraband (14) vi. Resisted D1/D2 patterns
 * Phase 3 (8-12 weeks):**
 * 1) Glenohumeral joint mobilizations – full ROM at 12 weeks
 * 2) Strengthening
 * 3) Continue therapist resistance for isometrics
 * 4) Add therabands/dumbbells:

Blackburns: 6 prone positions to isolate the rotator cuff/shoulder muscles based on position of the arm during the exercise. media type="youtube" key="Q6xDe4p1jVM" height="315" width="560"
 * 1) Supraspinatus isolated in scaption with palm toward floor
 * 2) Supraspinatus and infraspinatus in scaption with thumb up
 * 3) Infraspinatus isolated in 90 deg abduction with thumb up
 * 4) Teres minor isolated in extension with palm toward floor

Home exercise program of light resistance as fit.

 As a person moves into the chronic stage of healing it becomes important to focus more on strength and regaining proper function of the rotator cuff. It is this point in the rehab process that the remodeling phase has been completed, and because of that the tissue is able to handle increase stress. For a patient to be considered in the chronic phase of healing they should be pain free in ADL’s and should not use muscle substitution or compensation patterns during exercises (18) In a study done comparing independent home exercise program to receiving occupational therapy as treatment, it was found that a quality program was just as effective as OT. The study also laid out a lengthy list of exercises that can be used to help rehab a rotator cuff tear. These exercises are separated into what period of rehab they should be utilized. Around week 5-6 an individual should begin resisted abduction exercises, as well as performing advanced stretching exercises. It is noticed that a low rep (10) protocol is being called for with these resistance exercises. This assists in increasing strength. Finally, it was seen that with an exercise program patients had more of an increase in abduction ROM and abduction peak torque (12). There are also several exercises that can be done to better target the posterior rotator cuff muscles when you first begin strengthening exercises. Infraspinatous and Teres Minor: External rotation of shoulder with arm abducted to 45 degrees Supraspinatous: External Rotation of shoulder with arm abducted to 90 degrees. Both of these exercises are done in a standing position. (12)
 * Chronic**
 * Resisted abduction I || Subject is sitting, holding a resistance band in hands, one hand fixing at hip level, the other with hanging shoulder and flexed elbow; subject performs abduction until horizontal position (avoiding rotation or flexion). Start with the healthy side first || 10 reps x 3 || Week 5 ||  ||
 * Door stretch II || Subject is standing with both hands on a door frame, shoulder in abduction and elbows at head level; subject leans in and stretches anterior shoulder || 5 reps x 3 || Week 6 ||  ||
 * Resisted abduction II || Subject is sitting with hanging shoulders and flexed elbows, holding a crossed resistance band in hands; subject performs an abduction until horizontal position (avoiding rotation or flexion) || 10 reps x 3 || Week 6-8 ||  ||
 * Wall stretch I || Subject is standing sideways with one hand at a wall, shoulder in 90° abduction and elbow flexed; subject elevates arm until full elbow extension. || 10 reps x 3 || Week 7 ||  ||
 * Resisted abduction II || Subject is sitting, holding a resistance band in hands, one hand fixing at hip level, the other with hanging shoulder and flexed elbow; subject performs a widest possible abduction (avoiding rotation or flexion). Start with the healthy side first || 10 reps x 3 || Week 7 ||  ||
 * Wall stretch II || Subject is standing sideways with one hand at a wall, shoulder in 90° abduction and elbow flexed; subject leans in towards the wall and elevates arm as possible. || 10 reps x 3 || Week 8 ||  ||

It is also necessary to perform exercises that the scapular stabilizers as well, especially if the rotator cuff is weakened because of the tear. To do this a patient needs to target the serratus anterior muscle. This be done by performing a punch using a theraband, or performing pushups. Depending on the stage of rehab the patient can be progressed through pushups by starting vertical against a wall, to a table, to a step, then to the floor. This progression gradually increases the effect of gravity. (18)



Finally, at the latter parts of the chronic phase it is important to begin plyometrics, as it helps prepare the patient for the forces the shoulder will encounter upon return to sport. The patient starts by throwing a ball against a wall or rebounder with both hands, starting at chest level. They can progress to using only the injured arm while still maintaining a chest level start position. Then finish by advancing to overhead throwing, again still using just the injured extremity (18).

It has also been shown that for individuals with a massive rotator cuff injury an exercise program (with the assist of corticosteroid injections) without surgery can be helpful in improving the function of the shoulder by training muscle strength, coordination and proprioception. However, overall there is no a lot of evidence that supports the use of just exercise versus surgery followed by exercise. More research needs to be done to get conclusive findings. In a study comparing aquatic and land therapy to purely land based therapy it was seen that aquatics can be beneficial for improving rate of recovery of ROM and decreasing secondary complications. It has also been found to be a safe additive to regular therapeutic exercise. It recognizes though that further studies need to be done to determine the full benefits. Those patients seeking aquatic therapy should progress through three stages: buoyancy assisted ROM, buoyancy supported ROM, resistive. This means that the initial exercises are going to take place more towards the surface of the water, so buoyancy of the water is going to aid in performing the exercises. Therefore, the resistance the rotator cuff muscles are encountering during these movements is decreased. Which is typical for any sub-acute exercise progression, whether it be on land or in the water. On land these are similar to gravity assisted exercises. The next step is buoyancy supported, these activities occur in a fashion that is parallel with the bottom of the pool. These are similar to gravity eliminated exercises on land. That is, the buoyancy of the water is not helping you perform the exercise, but it is not going against the exercise either. Finally, resistive exercises are going against the buoyancy of the water, and are done to help increase strength of the muscles. These are similar to against gravity exercises on land (Dutton). The first phase, buoyancy assisted, begins 10 days post-op (after the stitches have been removed). Also, it is important to keep in mind that these aquatic exercises should done in combination with some of the land based exercises listed above. A possible water based therapy progression is as follows (4) Day 10: Buoyancy assisted Forward Flexion (FF) and ER Pendulum Week 6: Standing Breastroke Hand behind back Kickboard Week 8: Resisted FF and ER with paddles Week 10: Ball proprioception and resistance Wall push ups.
 * Aquatic Therapy **

Kickboard: media type="youtube" key="Pfluv3EDiaI" height="315" width="560"

<range type="comment" id="421084760_6"> </range id="421084760_6">
 * References:**
 * 1) American Academy of orthopaedic surgeons. (2011, May). American academy of orthopaedic surgeons Retrieved from []
 * 2) // Arthroscopic rotator cuff repair // . (2013, March 29). Retrieved from []
 * 3) Becker-Russell, K. (2011, August 6). Retrieved from []
 * 4) Brady, B. (2008, June 11). // The addition of aquatic therapy to rehabilitation following surgical rotator cuff repair: a feasibility study // . Retrieved from []
 * 5) Dutton, M. (2012). // Physical therapist assistant exam review guide // . (p. 471). Sudbury, MA: Jones & Bartlett Learning.
 * 6) Garofalo, R., Conti, M., Notarnicola, A., Maradei, L., Giardella, A., & Castagna, A. (2010). Effects of one-month continuous passive motion after arthroscopic rotator cuff repair: results at 1-year follow-up of a prospective randomized study. // Musculoskeletal surgery //, // 94 Suppl 1 // , S79–83. doi:10.1007/s12306-010-0058-7
 * 7) Green, W. (2010, January 07). // Web md // . Retrieved from []
 * Ja, C., Buchbinder, R., Green, S., Rv, J., & Sn, B. (2009). Surgery for rotator cuff disease ( Review ), (1).
 * 1) // Mayo clinic // . (2010, August 21). Retrieved from []
 * 2) Koo, S. S., Parsley, B. K., Burkhart, S. S., & Schoolfield, J. D. (2011). Reduction of postoperative stiffness after arthroscopic rotator cuff repair: results of a customized physical therapy regimen based on risk factors for stiffness. // Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association //, // 27 // (2), 155–60. doi:10.1016/j.arthro.2010.07.007
 * 3) Kovacevic, D., & Rodeo, S. a. (2008). Biological augmentation of rotator cuff tendon repair. // Clinical orthopaedics and related research //, // 466 // (3), 622–33. doi:10.1007/s11999-007-0112-4
 * 4) Krischak, G. (2013). A prospective randomized controlled trial comparing occupational therapy with home-based exercises in conservative treatment of rotator cuff tears. //Journal of Shoulder and Elbow Surgery, S1058-2746(13).//
 * 5) Kuhn, J. E., Dunn, W. R., Sanders, R., An, Q., Baumgarten, K. M., Bishop, J. Y., Brophy, R. H., et al. (2013). Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears : a multicenter prospective cohort study for the MOON Shoulder Group, (07), 1–9.
 * 6) O'Malley, D. F. (n.d.). // Rotator cuff repair protocol // . Retrieved from [|http://dukeorthoraleigh.com/pdf/pt protocol/SHOULDER - ROTATOR CUFF REPAIR.pdf]
 * 7) // Orthopod // . (2006, July 20). Retrieved from []
 * 8) Parsons, B. O., Gruson, K. I., Chen, D. D., Harrison, A. K., Gladstone, J., & Flatow, E. L. (2010). Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? // Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] //, // 19 // (7), 1034–9. doi:10.1016/j.jse.2010.04.006
 * 9) Ruiz-Suarez, M., & Barber, F. A. (2008). Postoperative pain control after shoulder arthroscopy. // Orthopedics //, // 31 // (11), 1130. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19226085
 * 10) Van der Meijden, O. a, Westgard, P., Chandler, Z., Gaskill, T. R., Kokmeyer, D., & Millett, P. J. (2012). Rehabilitation after arthroscopic rotator cuff repair: current concepts review and evidence-based guidelines. // International journal of sports physical therapy //, // 7 // (2), 197–218.
 * 11) Vorvick, L. J. (2011, June 30). // Medline plus // . Retrieved from []