Rotator Cuf f Repair: Rehabilitation Weeks 1-4 - TOCA, The

Rotator Cuf f Repair: Rehabilitation Weeks 1-4 - TOCA, The

78 PHYSICAL THERAPY CASE FILES: ORTHOPAEDICSFigure 5-1. Right humeral rotation ROM with the glenohumeral joint in the scapular plane.and scapular planes. Therefore, based on this study, early PROM should be performedinto the directions of both external and internal humeral rotation using the scapularplane position to minimize tensile loading in the repaired tendon. 18 Figure 5-1 showsa technique used to perform humeral rotation ROM with the glenohumeral jointplaced in the scapular plane. The use of a platform or the therapist’s leg provides asupported position in the scapular plane allowing the therapist’s hands to be free toprovide support to mobilize the humeral head.Another cadaveric study provides guidance for ROM application in the early postoperativephase. Muraki et al. 19 studied the effects of passive upper extremity motionon tensile loading of the supraspinatus tendon in human cadavers. They found nosignificant increases in strain in either the supraspinatus or infraspinatus tendonsat 60° of shoulder flexion during the movement of horizontal adduction. However,internal rotation performed at 30° and 60° of flexion increased tension in the inferiormostportion of the infraspinatus tendon compared to the resting or neutral position.This study provides additional guidance to therapists for selecting safe ROM positionsfollowing surgery: the use of internal rotation and cross arm adduction ranges ofmotion can be performed while putting minimal strain in the repaired supraspinatustendon. This study also illustrated the importance of knowing the degree of tendoninvolvement and repair because posteriorly based rotator cuff repairs (those involvingthe infraspinatus and teres minor) may be subjected to increased tensile loads if earlyinternal rotation is applied during postoperative rehabilitation. Therefore, communicationbetween the surgeon and treating physical therapist is of vital importance toensure that optimal range of motion is performed following repair.One area of initial concern in the rehabilitation process following rotator cuffrepair is the progression from PROM to active assisted range of motion (AAROM)Brumitt_Case-5_p073-084.indd 7812/26/12 5:42 PM

SECTION II: THIRTY-FOUR CASE SCENARIOS 79and active range of motion (AROM). Some disagreement regarding the degree ofmuscular activation occurring during these commonly used rehabilitation activitiescan be clarified by a review of the appropriate literature. Research by McCann etal. 20 provided clear delineation of the degree of muscular activation of the supraspinatusduring supine assisted flexion range of motion and seated elevation with the use of apulley. While both activities arguably produce low levels of inherent muscular activationin the supraspinatus, the seated upright pulley activity produced significantlymore muscular activity compared to the similar supine activities. This study clearlydemonstrated the effect of patient positioning on muscular activation and providestherapeutic rationale for the use of supine, gravity-neutral elevation exercise inthe early phase following rotator cuff repair to protect the healing tendon.Ellsworth et al. 21 have quantified levels of muscular activation during Codmanpendulum exercise . Their study showed minimal levels of muscular activation inthe rotator cuff musculature during Codman pendulum exercise. However, this exercisecannot be considered passive because the musculature is still activated, especiallyin individuals with shoulder pathology. While many therapists (including theauthors of this case) do not recommend the use of weight application in the handduring pendulum exercises due to the potential for unwanted anterior glenohumeraltranslation, Ellsworth et al. 21 found that muscular activity in the rotator cuff musculaturewas unchanged with and without weight application during the performanceof pendulum exercises. Pendulum exercises (with or without weight) still activaterotator cuff musculature, which calls into question their prescription in the earlypostsurgery phase in cases when only passive movements may be indicated.These studies give objective guidance for the early application of active assistedROM activities that can be applied safely in the early postsurgical rehabilitation followingrotator cuff repair. As further research becomes available, physical therapistswill be able to make evidence-based decisions regarding the appropriateness of specificrehabilitation exercises based on their inherent muscular activation. Rehabilitationin the first 2 to 4 weeks following rotator cuff repair typically consists of theuse of truly passive, as well as several minimally active or active assisted exercises forthe rotator cuff such as active assisted flexion using overhead pulleys and pendulumexercises. To recruit rotator cuff and scapular muscular activity, the patient can usethe “balance point” position (90° of shoulder flexion) in supine; the patient is cuedto perform small active motions of flexion/extension from the 90° starting position.These exercises should be coupled with early scapular stabilization via manual resistancetechniques emphasizing direct hand contacts on the scapula to bypass forceapplication to the rotator cuff and optimize trapezius, rhomboid, and serratus anteriormuscular activation ( Fig. 5-2 ). Kibler et al. 22 quantified the muscular activity(via electromyography) during low-level closed chain exercises such as weight shiftingon a rocker board (patient in a standing position with upper extremity resting ona rocker board sitting on a table top). They showed that this activity produced lowlevels of activation of the rotator cuff and scapular musculature (

80 PHYSICAL THERAPY CASE FILES: ORTHOPAEDICSFigure 5-2. Therapist applying manual resistance on patient’s scapula to facilitate trapezius,rhomboid, and serratus anterior muscular activation.anchor fixation model to withstand active loading in a similar fashion to transosseousrepair used during mini-open and open rotator cuff repair. Future research will helpto identify the effects of simulated submaximal loads on rotator cuff repair constructsto allow for optimal application of resistive exercise sequences for patients followingrotator cuff repair.In the initial phase of rehabilitation (1-4 weeks postsurgical repair), care mustbe taken regarding strengthening because the priority in this phase is to optimizeshoulder ROM, protect the repair, and initiate scapular stabilization. The use ofAROM exercises such as sidelying external rotation against gravity with little or noweight application can be prescribed to begin activating the posterior rotator cuffmusculature ( Fig. 5-3 ). This exercise has been shown to produce levels of muscularactivation of the infraspinatus and teres minor muscles in experimental electromyographicresearch studies. 24, 25 As the patient progresses, emphasis shifts to strengtheningof the entire rotator cuff complex. In this early phase, exercises are also appliedwith elastic resistance to provide an isometric contraction of the internal and externalhumeral rotators (rotator cuff) through the use of an exercise commonly called“dynamic isometrics” or step-outs ( Fig. 5-4 ). A small towel roll is placed under theaxilla during the exercise to place the shoulder in the scapular plane. 7 The use ofelastic resistance allows the physical therapist to ensure that the patient is not exercisingwith loads that exceed his present tolerance due to standardized elongationparameters of the Thera-Band colored tubing progression (Hygenic Corp, AkronOH). Elastic resistance is preferred over other methods of isometric exercise using awall or pillow in which the physical therapist has less ability to control or monitorthe patient’s exercise intensity.Brumitt_Case-5_p073-084.indd 8012/26/12 5:42 PM

SECTION II: THIRTY-FOUR CASE SCENARIOS 81Figure 5-3. Sidelying external rotation against gravity with small dumbbell weight to begin activatingposterior rotator cuff musculature.Figure 5-4. Resistanceexercise for right humeralrotator cuff complex. Rollunder the axilla keeps theshoulder in the scapularplane. The exercise isperformed by taking a stepaway (“step-out”) from theband’s attachment site whilemaintaining the same upperextremity position.Brumitt_Case-5_p073-084.indd 8112/26/12 5:42 PM

82 PHYSICAL THERAPY CASE FILES: ORTHOPAEDICSKey components of rehabilitation in the first month following rotator cuff repairinclude the use of early shoulder ROM, glenohumeral joint mobilization, submaximalrotator cuff and scapular active movement, and subtle resistance. Basic scienceresearch can be applied during this initial stage to ensure that appropriate loadingparameters are encountered by the postsurgical tissue to produce successful ROMand strength outcomes following rehabilitation. Future research will further elucidateoptimal loading and immobilization periods following surgical repair of therotator cuff.Evidence-Based Clinical RecommendationsSORT: Strength of Recommendation TaxonomyA: Consistent, good-quality patient-oriented evidenceB: Inconsistent or limited-quality patient-oriented evidenceC: Consensus, disease-oriented evidence, usual practice, expert opinion, or case series1. Supine, gravity-neutral elevation exercise is advocated to protect the healingtendon in the first 4 weeks after surgical rotator cuff repair. Grade B2. Codman pendulum exercises (with or without weight) in the early postsurgeryphase when only passive movements may be indicated may not be appropriatesince this exercise still activates rotator cuff musculature. Grade B3. In the first 4 weeks after surgical repair of the rotator cuff, a rehabilitation programemphasizing early shoulder ROM, glenohumeral joint mobilization, submaximalrotator cuff and scapular active movement, and subtle resistance produces goodpatient outcomes for range of motion, muscular strength, and shoulder function.Grade CCOMPREHENSION QUESTIONS5.1 In the fi rst 4 weeks following rotator cuff repair, the application of humeralrotation range of motion should be done in which of the following planes tominimize loading and tension on the repair?A. Sagittal planeB. Scapular planeC. Coronal planeD. Transverse plane5.2 Which of the following is not a component of early rehabilitation followingrotator cuff repair?A. Scapular stabilization exerciseB. Glenohumeral joint mobilizationC. Aggressive strengthening of the supraspinatusD. Submaximal activation of the posterior rotator cuffBrumitt_Case-5_p073-084.indd 8212/26/12 5:42 PM

SECTION II: THIRTY-FOUR CASE SCENARIOS 83ANSWERS5.1 B. Hatakeyama et al. 18 have shown in cadaveric research that humeral rotationexercise performed in the scapular plane produces less tensile loading than similarranges of motion performed in the sagittal plane.5.2 C. Aggressive loading of the rotator cuff has been shown to produce failures inboth traditional transosseous repair constructs as well as single and double rowsuture anchor fi xation methods. Care must be taken when implementing loadingstrategies to the repaired rotator cuff following surgical repair in the earlypostoperative period. 23REFERENCES1. Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain in the overhand or throwing athlete. The relationshipof anterior instability and rotator cuff impingement. Orthop Rev. 1989;28:963-975.2. Cofield RH. Current concepts review of rotator cuff disease of the shoulder. J Bone Joint Surg Am.1985;67:974-979.3. Andrews JR, Alexander EJ. Rotator cuff injury in throwing and racquet sports. Sports Med ArthroscopRev. 1995;3:30-38.4. Neer CS II. Impingement lesions. Clin Orthop Relat Res .1983;173:70-77.5. Codman EA. The Shoulder. 2nd ed. Brooklyn, NY: Miller & Medical; 1934.6. Chansky HA, Iannotti JP. The vascularity of the rotator cuff. Clin Sports Med. 1991;10:807-822.7. Rathbun JB, Macnab I. The microvascular pattern of the rotator cuff. J Bone Joint Surg Br .1970;52:540-553.8. Brooks CH, Revell WJ, Heatley FW. A quantitative histological study of the vascularity of therotator cuff tendon. J Bone Joint Surg Br. 1992;74:151-153.9. Swiontowski MF, Iannotti JP, Boulas HJ, et al. Intraoperative assessment of rotator cuff vascularityusing laser Doppler flowmetry. In: Post M, Morrey BF, Hawkins RJ, eds. Surgery of the Shoulder.St. Louis, MO: Mosby Year Book; 1990:208-212.10. Iannotti JP. Lesions of the rotator cuff: pathology and pathogenesis. In: Matsen FA, Fu FH, HawkinsRJ, eds. The Shoulder: A Balance of Mobility and Stability. Rosemont, IL: American Academy of OrthopaedicSurgeons; 1993.11. Loehr JF, Helmig P, Sojbjerg JO, Jung A. Shoulder instability caused by rotator cuff lesions. An invitro study. Clin Orthop Relat Res. 1994;304:84-90.12. Miller C, Savoie FH. Glenohumeral abnormalities associated with full-thickness tears of the rotatorcuff. Orthop Rev. 1994;23:159-162.13. Ellenbecker TS. Clinical Examination of the Shoulder . St. Louis, MO: W.B. Saunders; 2004.14. Kibler WB. Role of the scapula in the overhead throwing motion. Contemp Orthop . 1991;22:525-532.15. Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation ofscapular dysfunction: a reliability study. J Shoulder Elbow Surg . 2002;11:550-556.16. Gerber C, Ganz R. Clinical assessment of instability of the shoulder. With special reference toanterior and posterior drawer tests. J Bone Joint Surgery. 1984;66:551-556.17. McFarland EG, Torpey BM, Curl LA. Evaluation of shoulder laxity. Sports Med. 1996;22:264-272.18. Hatakeyama Y, Itoi E, Urayama M, Pradham RL, Sato K. Effect of superior capsule and coracohumeralligament release on strain in the repaired rotator cuff tendon. A cadaveric study. Am J SportsMed . 2001;29:633-640.Brumitt_Case-5_p073-084.indd 8312/26/12 5:42 PM

84 PHYSICAL THERAPY CASE FILES: ORTHOPAEDICS19. Muraki T, Aoki M, Uchiyama E, Murakami G, Miyamoto S. The effect of arm position on stretchingof the supraspinatus, infraspinatus, and posterior portion of deltoid muscles: a cadaveric study. ClinBiomech. 2006;21:474-480.20. McCann PD, Wooten ME, Kadaba MP, Bigliani LU. A kinematic and electromyographic study ofshoulder rehabilitation exercises. Clin Orthop Rel Res. 1993;288:178-188.21. Ellsworth AA, Mullaney M, Tyler TF, McHugh M, Nicholas S. Electromyography of selected shouldermusculature during un-weighted and weighted pendulum exercises. N Am J Sports Phys Ther.2006;1:73-79.22. Kibler WB, Livingston B, Bruce R. Current concepts in shoulder rehabilitation. In: Stauffer RN,Erlich MG. Advances in Operative Orthopaedics. Vol 3 . St Louis, MO: Mosby; 1995:249-297.23. Tashjian RZ, Levanthal E, Spenciner DB, Green A, Fleming BC. Initial fixation strength of massiverotator cuff tears: in vitro comparison of single-row suture anchor and transosseous tunnel constructs.Arthroscopy. 2007;23:710-716.24. Townsend H, Jobe FW, Pink M, Perry W. Electromyographic analysis of the glenohumeral musclesduring a baseball rehabilitation program. Am J Sports Med. 1991;19:264-272.25. Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus anddeltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007;42:464-469.Brumitt_Case-5_p073-084.indd 8412/26/12 5:42 PM

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