REHABILITATION PROTOCOL FOR ROTATOR CUFF TEAR

Presented by: Elizabeth B. Perez Physiotherapist 2

bones and joints

Ligaments and Tendons

Ligaments attach the clavicle to the acromion in the AC joint. Two ligaments connect the clavicle to the scapula by attaching to the coracoid process, a bony knob that sticks out of the scapula in the front of the shoulder.

Labrum
A special type of ligament forms a unique structure inside the shoulder called the labrum.

Bursae
synovial fluid filled sacs which function to decrease friction between bony prominences. 1. subacromial 2. subdeltoid 3. subscapular

The Rotator Cuff Muscles

common tendon covering top, front, & back of humeral head; - 4 muscles fuse to form this tendon: (subscapularis, supraspinatus,, infraspinatus, teres minor;) - supraspinatus - lies directly over top of humeral head & is an abductor; - it is predisposed to degenerative changes because of its location between humeral head & acromion, which compress tendon during shoulder movement - infraspinatus & teres minor - cover back of humeral head & are external rotators; - distal aspect of the rotator cuff, the supraspinatus and infraspinatus tendons splay out and interdigitate, forming a common continuous insertion on middle facet of the humeral greater tuberosity; - subscapularis: crosses front of shoulder joint, is internal rotator and reinforces anterior capsule;

Innervation and Blood supply

- innervation: - supraspinatus & infraspinatus are supplied by the suprascapular nerve; - teres minor is supplied by axillary nerve; - subscapularis is supplied by subscapular nerve; - blood supply: - blood supply to the rotator cuff is derived from 6 arteries; - anterior humeral circumflex - is major supplier to anterior cuff & long head of the biceps; - postrior humeral circumflex - along w/ suprascapular branch supplies the posterior cuff; - suprascapular - thoracoacromial arteries - supplies the supraspinatus - suprahumeral - subscapular

Rotator Cuff Tear

Is a common cause of shoulder pain and disability. a rotator cuff injury sustained without physical trauma can be thought of as a continuation of an impingement problem, specifically of the supraspinatus tendon because it is directly under the acromion process and has very poor vascularity. Repetitive actions, especially overhead activities cause repeated microtrauma leading to the physical wearing of a hole in the involved tendon(s) The frequency of rotator cuff tears increases with age, with full-thickness tears uncommon in patients younger than 40 years. The rotator cuff "complex" refers to the tendons of four muscles: S-S-I-T subscapularis, supraspinatus, infraspinatus,and teres minor These four muscles originate on the scapula, cross the GH joint, then transition into tendons that insert onto the tuberosities of the proximal humerus

Rotator Cuff Tear (continued)

The rotator cuff has three well-recognized functions: rotation of the humeral head, stabilization of the humeral head in the glenoid socket by compressing the round head into the shallow socket, and the ability to provide "muscular balance," stabilizing the GH joint when other larger muscles crossing the shoulder contract

Rotator Cuff Integrity Tests

1. Empty-Can (Supraspinatus) test

2. Drop-arm (Codmans) test

3. Gerber Lift-Off Sign

Classifications of Rotator Cuff tear

Acute or Chronic, based on their timing Acute Tears: Patients with acute tears of the rotator cuff usually present to their physician after a traumatic injury. Complaints of pain and sudden weakness, which may be manifested by an inability to elevate the arm. On physical examination, a weakness in shoulder motion of forward elevation, external rotation, or internal rotation depending on which cuff muscles are involved. If the injury is chronic and the patient has been avoiding using the shoulder because of pain, there may be concomitant adhesive capsulitis (limitation of passive shoulder motion) and weakness of active ROM (underlying rotator cuff tear). Treatment: The recommended treatment for active patients with acute tears of the rotator cuff is surgical repair.

Classifications of Rotator Cuff tear

Continued
Chronic Tears: may be an asymptomatic pathologic condition that has an association with the normal aging process. A variety of factors, including poor vascularity, a "hostile" environment between the coracoacromial arch and the proximal humerus, decreased use, or gradual deterioration in the tendon, contribute to the senescence of the rotator cuff, especially the supraspinatus. Several factors contribute to degenerative, or chronic, rotator cuff tears. Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well. Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear. Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

Classifications of Rotator Cuff tear Continued

Treatment of most patients with a chronic tear of the

rotator cuff follows conservative rehabilitation program. Operative intervention in this patient population is indicated for patients who are unresponsive to conservative management or demonstrate an acute tear and have vague complaints of intermittent shoulder pain that has become progressively more symptomatic. These patients may also have a history that is indicative of a primary impingement etiology.

Classifications of Rotator Cuff tear Continued

Partial (articular or bursal side) or Complete, based on the depth of the tear
Classification of Complete tear: described by Post (1983): small (0-1 cm2 ), medium (1-3 cm2),

large (3-5 cm2), or

massive (>5 cm2

Factors Affecting Rehabilitation after Repair of Rotator Cuff Tears

Type of Repair Open Mini-open Arthroscopic Size of Tear Absolute size Number of tendons involved Patient's Tissue Quality Good, fair, poor Location of Tear Superior tear Superoposterior Superoanterior Surgical Approach Onset of Tissue Failure Acute or gradual onset Timing of repair Patient Variables Age Dominant or nondominant arm Preinjury level Desired level of function (work and sports) Work situation Patient compliance with therapy regimen Rehabilitation Situation Supervised or unsupervised Physicians Philosophic Approach
From Wilk KE, Crockett He. Andrews JR: Rehabilitation after rotator cuff surgery. Tech Shoulder Elbow Surg 1(2): 128-144, 2000.

Type of Repair
Patients who have had deltoid muscle detachment or release from the acromion or clavicle (e.g., traditional open rotator cuff repair) may not perform active muscle contractions of the deltoid for 6 to 8 weeks. This is avoided to prevent avulsion of the deltoid. Arthroscopic repair of the cuff actually has a slightly slower rate of rehabilitation progression owing to the weaker fixation of the repair compared with that of the open procedure. A mini-open procedure, involving a vertical split with the orientation of the deltoid fibers, allows mild, earlier deltoid muscular contractions. *Regardless of the surgical approach performed, the underlying biology of healing tendons must be respected for all patients.

Size of the Tear

Functional outcome and expectation after rotator cuff surgery are directly related to the size of the tear repaired. Wilk and Andrews (2002) base the rate of rehab on the size and extent of the tear

Tissue Quality

The quality of the tendon, muscular tissue, and bone helps determine speed of rehabilitation
Thin, fatty, or weak tissue is progressed slower than excellent tissue

Location of the Tear

Tears that involve posterior cuff structures require a slower progression in external rotation strengthening. Rehabilitation after subscapularis repair (anterior structure) should limit resisted internal rotation for 4 to 6 weeks. Restriction of the amount of passive external rotation motion should also be restricted until early tissue healing has occurred. Most tears occur and are confined to the supraspinatus tendon, the critical site of wear, often corresponding to the site of subacromial impingement

Onset of the Rotator Cuff Tear and the Timing of the Repair
Acute tears with early repair may have a slightly greater propensity to develop stiffness, and we are a little more aggressive in the ROM program Cofield (2001) noted that patients who underwent an early repair progressed more rapidly with rehabilitation than those with a late repair.

Patient Variables
Several authors have reported a less successful outcome in older patients than young. This may be due to older patients typically having larger and more complex tears, probably affecting outcome

Several studies have noted no difference in outcome based on arm dominance. Hawkins and associates (1991) noted that worker's compensation patients required twice as long to return to work compared with their non-worker's compensation cohorts.

Rehabilitation Situation and Surgeon's Philosophic Approach

Finally, researchers have noted a correlation between preoperative shoulder function and outcome after surgical repair. Generally, patients who have an active lifestyle before surgery return to the same postop.
A skilled shoulder therapist is recommended rather than a home therapy program. Lastly, some physicians prefer more aggressive progression, whereas others remain very conservative in their approach Rehabilitation after rotator cuff surgery emphasizes immediate motion, early dynamic GH joint stability, and gradual restoration of rotator cuff strength Throughout rehabilitation, overstressing of the healing tissue is to be avoided, striking a balance between regaining shoulder mobility and promoting soft tissue healing.

Basic Rehabilitation Goals after Rotator Cuff Repair

Goal 1 : Maintain integrity of the repaired rotator cuff. Never overstress healing tissue.

Goal 2: Reestablish full passive ROM as quickly and safely as possible.

Goal 3 : Reestablish dynamic humeral head control. Do not work through a shoulder shrug! Goal 4: Improve external rotation muscular strength. Reestablish muscular balance.

Goal 5: Initiate resisted shoulder abduction and flexion when muscular balance is restored.
Goal 6: Caution against overaggressive activities (tissue-healing constraints). Goal 7: Restore patient's functional use of shoulder, but do so gradually. Goal 8: Activate rotator cuff muscles through inhibition of pain.

Rehabilitation Protocol For Patients with Chronic Rotator Cuff Tears-Treated Conservatively (Non operatively)
Phase 1: Weeks 0-4
Restrictions Avoid provocative maneuvers or exercises that cause discomfort . Includes both offending ROM exercises and strengthening exercises. Patients may have an underlying subacromial bursitis, therefore ROM exercises, and muscle strengthening exercises should begin with the arm in less than 90 degrees of abduction. Avoid abduction-rotation - re-creates impingement maneuver.

Avoid "empty-can" exercises.

Rehabilitation Protocol For Patients with Chronic Rotator Cuff Tears-Treated Conservatively (Non operatively) (Continued)
Immobilization
Brief sling immobilization for comfort only. Pain Control Reduction of pain and discomfort is essential for recovery.

Medications
NSAlDs-for the older population with additional comorbidities, consider newer cyclooxygenase-2 (COX-2) inhibitors. Subacromial injection of corticosteroid and local anesthetic; judicious use for patients with acute inflammatory symptoms of a concomitant bursitis; limit of three injections. Therapeutic modalities Ice, ultrasound, HVGS. Moist heat before therapy, ice at end of session.

Rehabilitation Protocol For Patients with Chronic Rotator Cuff Tears-Treated Conservatively (Non operatively) (Continued)
Shoulder Motion Goals Internal and external rotation equal to contralateral side, with the arm positioned in less than 90 degrees of abduction Exercises Begin with Codman pendulum exercises to gain early motion.

Passive ROM exercises

Shoulder flexion. Shoulder extension. Internal and external rotation.

Capsular stretching for anterior, posterior, and inferior capsule by using the opposite arm

Rehabilitation Protocol For Patients with Rehabilitation Protocol Chronic Rotator Cuff Tears-Treated Conservatively For Patients with Chronic Rotator Cuff(Continued) (Non operatively) Tears-Treated Conservatively) (Continued)
Avoid assisted motion exercises Shoulder flexion. Shoulder extension. Internal and external rotation. Progress to active ROM exercises "Wall-walking Elbow Motion Passive to active motion, progress as tolerated 0-130 degrees. Pronation to supination as tolerated. Muscle Strengthening Grip strengthening (putty, Nerf ball, racquetball). Use of the arm for activities of daily living below shoulder level. Phase 2: Weeks 4-8 Criteria for Progression to Phase 2 Minimal pain and tenderness. Improvement of passive ROM. Return of functional ROM.

Rehabilitation Protocol For Patients with Chronic Rotator Cuff Tears-Treated Conservatively Rehabilitation Protocol (Non operatively) (Continued)

For Patients with Chronic Rotator Cuff Tears-Treated Conservatively ( (Continued)

Goals Improve shoulder complex strength, power, and endurance. Restrictions Avoid provocative maneuvers or exercises that cause discomfort for the patient. Includes both ROM exercises and strengthening exercise Immobilization None. Pain Control Reduction of pain and discomfort is essential for recovery Medications NSAIDs-for older population with additional comorbidities, consider newer COX-2 inhibitor formulas. Subacromial injection of corticosteroid and local nesthetic; judicious use for patients with acute inflammatory symptoms of a concomitant bursitis; limit of three injections.

Rehabilitation Protocol For Patients with Chronic Protocol Tears-Treated Conservatively Cuff Rehabilitation Rotatoroperatively) (Continued) (Non

For Patients with Chronic Rotator Cuff Tears-Treated Conservatively (N (Continued)

Therapeutic modalities Ice, ultrasound, HVGS. Moist heat before therapy, ice at end of session. Motion Goal Equal to contralateral shoulder in all planes of motion. Exercises Passive ROM. Capsular stretching. Active-assisted motion exercises. Active ROM exercises. Muscle Strengthening Three times per week, 8 to 12 repetitions, for three sets. Strengthening of the remaining muscles of the rotator cuff. Begin with closed-chain isometric strengthening

Rehabilitation Protocol For Patients with Chronic Protocol Tears-Treated Conservatively Cuff Rehabilitation Rotatoroperatively) (Continued) (Non

For Patients with Chronic Rotator Cuff Tears-Treated

Continued)
Internal rotation. External rotation. Abduction. Progress to open-chain strengthening with Therabands Exercises performed with the elbow flexed to 90 degrees. Starting position is with the shoulder in the neutral position of 0 degrees of forward flexion, abduction, and external rotation. Exercises are done through an arc of 45 degrees in each of the five clinical planes of motion. Six color-coded bands are available, each provides increasing resistance from 1 to 6 pounds, at increments of 1 pound. Progression to the next band occurs usually in 2- to 3-wk intervals. Patients are instructed not to progress to the next band if there is any discomfort at the present level.

Rehabilitation Protocol For Patients with Chronic Protocol Tears-Treated Conservatively Cuff Rehabilitation Rotatoroperatively) (Continued) (Non

For Patients with Chronic Rotator Cuff Tears-Treated \sContinued)

Theraband exercises permit concentric and eccentric strengthening of the shoulder muscles and are a form of isotonic exercises (characterized by variable speed and fixed resistance) Internal rotation.
External rotation. Abduction. Forward flexion. Extension Progress to light isotonic dumbbell exercises Internal rotation. External rotation. Abduction. Forward flexion. Extension.

Rehabilitation Protocol For Patients with Chronic Protocol Tears-Treated Conservatively Cuff Rehabilitation Rotatoroperatively) (Continued) (Non

For Patients with Chronic Rotator Cuff Tears-Treated Conservatively ( (Continued)

Strengthening of deltoid (Fig. 3-58). Strengthening of scapular stabilizers Closed-chain strengthening exercises Scapular retraction (rhomboideus, middle trapezius). Scapular protraction (serratus anterior). Scapular depression (latissimus dorsi, trapezius, serratus anterior). Shoulder shrugs (upper trapezius). Progress to open-chain scapular stabilizer strengthening Goals Improve neuromuscular control and shoulder proprioception. Prepare for gradual return to functional activities. Establish a home exercise maintenance program that is performed at least three times per week for both stretching and strengthening. Functional Strengthening Plyometric exercises

Rehabilitation Protocol For Patients with Chronic Protocol Tears-Treated Conservatively Cuff Rehabilitation Rotatoroperatively) (Continued) (Non

For Patients with Chronic Rotator Cuff Tears-Treated Conservatively ( (Continued)

Progressive, systematic Interval Program for Returning to Sports Throwing athletes Tennis players Golfers Maximal Improvement is expected by 4-6 months Warning Signals Loss of motion especially internal rotation Lack of strength progression- especially abduction, forward elevation. Continued pain- especially at night.
Treatment of Warning Signal These patients may need to move back to earlier routines. May require increased utilization of pain control modalities as outlined above. May require surgical intervention

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff

Phase 1: Weeks 0-6 Restrictions No active ROM exercises. Active ROM exercises initiation based on size of tear Small tears (0-1 cm)-no active ROM before 4 wk Medium tears (1-3 cm)-no active ROM before 6 wk Large tears (3-5 cm)-no active ROM before 8 wk. Massive tears (>5 cm ROM)-no active ROM before 12 wk. Delay active-assisted ROM exercises for similar time periods based on size of tear.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont.

Passive ROM only 140 degrees of forward flexion. 40 degrees of external rotation. 60-80 degrees of abduction without rotation. No strengthening/resisted motions of the shoulder until 12 wk after surgery For tears with high healing potential (small tears, acute, patients younger than 50 years, nonsmoker), isometric strengthening progressing to Theraband exercises may begin at 8 wk. Strengthening exercises before 12 wk should be performed with the arm at less than 45 degrees of abduction. Immobilization Type of immobilization depends on amount of abduction required to repair rotator cuff tendons with little or no tension. Use of sling-if tension of repair is minimal or none with arm at the side

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont. Small tears-1-3 wk. Medium tears-3-6 wk. Large and massive tears-6-8 wk. Abduction orthosis-if tension of repair is minimal or none with the arm in 20-40 degrees of abduction Small tears-6 wk. Medium tears-6 wk. Large and massive tears-8 wk. Pain Control Patients treated with arthroscopic rotator cuff repair experience less postoperative pain than patients treated with mini-open or open repairs (but more tenuous repair). Medications Narcotic-for 7-10 day following surgery. NSAlDs-for patients with persistent discomfort following surgery. In the older population with additional comorbidities, consider newer COX-2 inhibitor formulas.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont. Therapeutic modalities Ice, ultrasound, HVGS. Moist heat before therapy, ice at end of session. Shoulder Motion Passive only 140 degrees of forward flexion. 40 degrees of external rotation. 60-80 degrees of abduction. For patients immobilized in abduction pillow, avoid adduction (Le., bringing arm toward midline). Exercises should begin "above" the level of abduction in the abduction pillow Begin Codman pendulum exercises to promote early motion. Passive ROM exercises only (see Fig. 3-35).

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont. Elbow Motion Passive-progress to active motion 0-130 degrees. Pronation and supination as tolerated. Muscle Strengthening Grip strengthening only in this phase. Phase 2: Weeks 6-12 Criteria for Progression to Phase 2 At least 6 wk of recovery has elapsed. Painless passive ROM to 140 degrees of forward flexion. 40 degrees of external rotation. 60-80 degrees of abduction. Restrictions No strengthening/resisted motions of the shoulder until 12 wk after surgery. During phase 2, no active ROM exercises for patients with massive tears.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont.

Immobilization Discontinuation of sling or abduction orthosis. Use for comfort only. Pain Control NSAlDs for patients with persistent discomfort following surgery. Therapeutic modalities Ice, ultrasound, HVGS. Moist heat before therapy, ice at end of session. Shoulder Motion Goals 140 degrees of forward flexion-progress to 160 degrees. 40 degrees of external rotation-progress to 60 degrees. 60-80 degrees of abduction-progress to 90 degrees.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont. Exercises Continue with passive ROM exercises to achieve above goals (see Fig. 3-35). Begin active-assisted ROM exercises for the above goals (see Fig. 3-34). Progress to active ROM exercises as tolerated after full motion achieved with active-assisted exercises. Light passive stretching at end ROMs Muscle Strengthening Begin rotator cuff and scapular stabilizer strengthening for small tears with excellent healing potential-as outlined below in phase 3. Continue with grip strengthening. Phase 3: Months 4-6 Criteria for Progression to Phase 3 Painless active ROM. No shoulder pain or tenderness. Satisfactory clinical examination.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont.

Goals Improve shoulder strength, power, and endurance. Improve neuromuscular control and shoulder proprioception. Prepare for gradual return to functional activities. Establish a home exercise maintenance program that is performed at least three times per week for strengthening. Stretching exercises should be performed daily. Motion Achieve motion equal to contralateral side. Use passive, active-assisted and active ROM exercises. Passive capsular stretching at end ROMs, especially cross-body (horizontal) adduction and internal rotation to stretch the posterior capsule.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont.

Muscle Strengthening Strengthening of the rotator cuff Begin with closed-chain isometric strengthening (see Fig. 3-36) Internal rotation. External rotation. Abduction. Forward flexion. Extension. Progress to open-chain strengthening with Therabands (see Fig. 3-39) Exercises performed with the elbow flexed to 90 degrees. Starting position is with the shoulder in the neutral position of 0 degrees of forward flexion, abduction, and external rotation. The arm should be comfortable at the patient's side.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont. Exercises are performed through an arc of 45 degrees in each of the five planes of motion. Six color-coded bands are available; each provides increasing resistance from 1 to 6 pounds, at increments of 1 pound. Progression to the next band occurs usually in 2to 3-wk intervals. Patients are instructed not to progress to the next band if there is any discomfort at the present level. Theraband exercises permit concentric and eccentric strengthening of the shoulder muscles and are a form of isotonic exercises (characterized by variable speed and fixed resistance) Internal rotation. External rotation. Abduction. Forward flexion. Extension.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont. Progress to light isotonic dumbbell exercises (see Fig. 3-39B) Internal rotation. External rotation. Abduction. Forward flexion. Extension. Strengthening of deltoid-especially anterior deltoid (see Fig. 3-58). Strengthening of scapular stabilizers Closed-chain strengthening exercises (Fig. 3- 59; see also Fig. 3-37) Scapular retraction (rhomboideus, middle trapezius). Scapular protraction (serratus anterior). Scapular depression (latissimus dorsi, trapezius, serratus anterior). Shoulder shrugs (trapezius, levator scapulae). Progress to open-chain scapular stabilizer strengthening (see Fig. 3-38).

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont. Goals Three times per week. Begin with 10 repetitions for one set, advance to 8 to 12 repetitions for three sets. Functional strengthening: (begins after 70% of strength recovered) Plyometric exercises (see Fig. 3-40). Progressive, systematic interval program for returning to sports Throwing athletes-see p. 190 Tennis players-see p. 193 Golfers-see p. 195 Maximal Improvement Small tears-4-6 mo. Medium tears-6-8 mo. Large and massive tears-8-12 mo. Patients will continue to show improvement in strength and function for at least 12 mo.

Rehabilitation Protocol After Surgical Repair of the Rotator Cuff Cont. Warning Signals Loss of motion-especially internal rotation. Lack of strength progression-especially abduction. Continued pain-especially at night. Treatment These patients may need to move back to earlier routines. May require increased utilization of pain control modalities as outlined above. May require repeat surgical intervention. Indications for repeat surgical intervention Inability to establish more than 90 degrees forward elevation by 3 months Steady progress interrupted by traumatic event and/or painful pop duringt the healing phase with a lasting loss of previously gained active motiion Radiographic evidence of loosened intraarticular implants after the injury in a post operative rehab period. The patient has a loss of active motion and or crepitance of the joint as well.

References:

The Body Almanac. (c) American Academy of Orthopaedic Surgeons, 2003. S. Brent Brotzman, K. E. Wilk, Clinical Orthopedic Rehabilitation, 2003 Wilk KE, Crockett He. Andrews JR: Rehabilitation after rotator cuff surgery. Tech Shoulder Elbow Surg 1(2): 128-144, 2000. http://scottsevinsky.com/pt/reference/shoulder/aaos_scapular_dyskinesis.p df