Rehabilitation Following Rotator Cuff Repair Kolleen Shields MS, P.T Hawkeye Sports Medicine Symposium

Terminology Partial Rotator Cuff Tears Partial Rotator Cuff Tears Full Rotator Cuff Tears Full Rotator Cuff Tears –Small (< 2 cm) –Medium (2-5 cm) –Large (> 5 cm) –Massive (involves 2 or more tendons)

Open Repairs vs. Arthroscopic Larger incision Larger incision Deltoid detachment Deltoid detachment More post-op pain More post-op pain Inpatient stay for pain control Inpatient stay for pain control Smaller incision Smaller incision Less post-op pain Less post-op pain Outpatient procedure Outpatient procedure Pain is not a good guide for rehab Pain is not a good guide for rehab

Information essential in designing a rehabilitation program: Nature of injury (type of tear) Nature of injury (type of tear) Extent of surgical repair Extent of surgical repair Restrictions set by physician Restrictions set by physician Restrictions as understood by client Restrictions as understood by client Concurrent medical conditions Concurrent medical conditions Pre-op level of function and mobility Pre-op level of function and mobility

Immediate post-operative goals (0-2 weeks) Control pain/swelling: Control pain/swelling: –Cryotherapy (Speer et al. J Shoulder Elbow Surg. 1996) (Speer et al. J Shoulder Elbow Surg. 1996) –Medications as prescribed –Use of sling to limit shoulder movement –Sleep position

Immediate post-operative goals (0-2 weeks) Early protective passive motion: Early protective passive motion: –Pendulums –Passive elevation ( degrees) –Table slides –Pulleys –Passive external rotation (0-20 degrees) –Elbow, wrist, hand active motion –Isometric grip strengthening –Periscapular isometrics

Early ROM Exercises

Table Slides

Immediate post- operative precautions Avoid extension movements beyond plane of body (4 weeks) Avoid extension movements beyond plane of body (4 weeks) Avoid any active lifting of the arm (elevation/abduction: 6 weeks) Avoid any active lifting of the arm (elevation/abduction: 6 weeks) Avoid active external rotation (4-6 weeks) Avoid active external rotation (4-6 weeks)

Posture Coracoacromial ligament and attachment to acromion form a “roof” under which the supraspinatus tendon, the biceps tendon and subacromial bursa must pass during elevation or abduction of the arm. Coracoacromial ligament and attachment to acromion form a “roof” under which the supraspinatus tendon, the biceps tendon and subacromial bursa must pass during elevation or abduction of the arm. At approx deg of active glenohumeral elevation, the greater tuberosity approaches the “roof” At approx deg of active glenohumeral elevation, the greater tuberosity approaches the “roof” Rounded shoulder posture narrows potential space of the “roof,” thus making it more likely that impingement may occur with elevation of the arm Rounded shoulder posture narrows potential space of the “roof,” thus making it more likely that impingement may occur with elevation of the arm

Postural sets

Progressive Rehabilitation (2-4 weeks) Continue pendulums and table slides Continue pendulums and table slides Passive elevation ( deg) Passive elevation ( deg) Passive external rotation (20-35 deg) Passive external rotation (20-35 deg) Initiate pulleys Initiate pulleys Tendon tissue healing requires the load across the tendon to be minimal for the first 4 weeks

Advanced passive motion

Progressive Rehabilitation (4-6 weeks) Continue passive motion exercises (elevation: deg, external rotation:30-45 deg) Continue passive motion exercises (elevation: deg, external rotation:30-45 deg) Add bilateral extension motion with cane Add bilateral extension motion with cane Add internal rotation for posterior capsule stretch Add internal rotation for posterior capsule stretch

Progressive Rehabilitation (6-8 weeks) A.A.R.O.M Gradually introduce controlled stretches across the healing tendon during the maturation process. Tissues need to see progressively increasing loads. Gradually introduce controlled stretches across the healing tendon during the maturation process. Tissues need to see progressively increasing loads. A.A.R.O.M for elevation: progression of wall walking, assisted supine cane exercises, supine bilateral arm raise A.A.R.O.M for elevation: progression of wall walking, assisted supine cane exercises, supine bilateral arm raise

Assisted wall walking

Progressive Rehabilitation (6-8 weeks) A.A.R.O.M A.A.R.O.M for internal rotation: cane behind back, towel stretch, clasp hands behind back A.A.R.O.M for internal rotation: cane behind back, towel stretch, clasp hands behind back A.A.R.O.M diagonal supine with cane A.A.R.O.M diagonal supine with cane A.A.R.O.M extension standing A.A.R.O.M extension standing A.A.R.O.M for external rotation (35-55 deg) A.A.R.O.M for external rotation (35-55 deg) Continued wall walking Continued wall walking Low level isometrics Low level isometrics

Progressive Rehabilitation (8-12 weeks) Continue with range of motion exercises working towards full functional mobility (mobilization?) Continue with range of motion exercises working towards full functional mobility (mobilization?) Should be able to raise arm above head Should be able to raise arm above head Add light resistance (cream/yellow) therabands: Add light resistance (cream/yellow) therabands: –Bilateral extension –Bilateral forward flexion (30 deg) –Bilateral external rotation –Triceps –Scapular retraction –Unilateral internal rotation –Abduction/Adduction

Progressive Active Elevation

Isometrics

Active Assistive Range of Motion

Progressive Theraband

Progressive Rehabilitation (8-12 weeks) Side lying external rotation (light weights) progressing from arm at side to arm away from side Side lying external rotation (light weights) progressing from arm at side to arm away from side Periscapular prone strengthening with weights Periscapular prone strengthening with weights Tricep strengthening Tricep strengthening Bicep curls Bicep curls

Periscapular Strengthening

Side Lying External Rotation

Triceps/Biceps Strengthening

Advanced Strengthening (12 weeks-6 months) Progression of theraband exercises Progression of theraband exercises Add closed chain exercises Add closed chain exercises PRE’s for external rotation, elevation, abduction PRE’s for external rotation, elevation, abduction

Cuff Strengthening in Abduction

Progression of Active Exercises

Progression of Stabilization Exercises

Highest Level Strengthening May Include “Full” range strengthening activities “Full” range strengthening activities Body blade Body blade Therapeutic ball activities Therapeutic ball activities Plyometric activities Plyometric activities Return to sport drills Return to sport drills

Full Range Strengthening

Therapuetic Ball Exercises

Body Blade

Plyometrics

Rehabilitation Following Rotator Cuff Tears

Initial Goals Control pain (cryotheraphy, medication, sling) Control pain (cryotheraphy, medication, sling) Begin gentle, passive/active assistive range of motion exercises Begin gentle, passive/active assistive range of motion exercises Sleep position Sleep position Rest arm Rest arm

Goals of Therapeutic Exercise Improve strength of surrounding musculature in order to regain functional use of the arm Improve strength of surrounding musculature in order to regain functional use of the arm Proceed slowly and use pain as a guide. Partial RCT can progress to full thickness tears.

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