Rotator cuff injuries.pptx
- 2. INTRODUCTION The rotator cuff is made up of muscles and tendons. It holds the top of the upper arm into the shoulder joint (socket). The rotator cuff is made up of four muscles. SUPRASPINATUS INFRASPINATUS TERES MINOR SUBSCAPULARIS The tendons attach the muscles to four shoulder bones: The shoulder blade (scapula) The upper arm bone (humerus) The collarbone (clavicle.) The tendons are broad, measuring approximately 5 centimeters in width, and form a cuff encapsulating the articular surface of the top of the humerus.
- 4. Rotator cuff tears Rotator cuff tears and subacromial impingement are among the most common causes of shoulder pain and disability. The frequency of rotator cuff tears increases with age, with full-thickness tears uncommon in patients younger than 40 years
- 5. Classification 1. On the basis of timing Acute Chronic 2. On the basis of depth of tear Partial Complete – on the basis of size (Post 1983) Small (0-1 cm2 ) Medium (1-3 cm2) Large (3-5 cm2) Massive (>5 cm2)
- 8. Acute Tear Patients with acute tears of the rotator cuff usually present to their physician after a traumatic injury. Mechanism of injury Fall on shoulder Lifting or throwing heavy object with overhead activity. Patient complaints of pain and sudden weakness, which may be manifested by an inability to elevate the arm.
- 9. On Examination On physical examination, they have a weakness in shoulder motion of forward elevation, external rotation, or internal rotation depending on which cuff muscles are involved. Passive motion is usually intact depending on the timing of presentation
- 10. Treatment The recommended treatment for active patients with acute tears of the rotator cuff is surgical repair. Advantages of early operative repair include mobility of the rotator cuff, which allows technically easier repairs, good quality of the tendon, which allows a more stable repair, and in the patients with cuff tears associated with a dislocation, the repair will improve GH joint stability.
- 11. Chronic tears Chronic rotator cuff 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. Many patients with a chronic rotator cuff tears are over the age of 50 years, have no history of shoulder trauma, 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.
- 12. Examination On physical examination, some evidence of muscular atrophy may be seen in the supraspinatus fossa. Depending on the size of the tear, there may also be atrophy in the infraspinatus fossa. Passive motion is usually maintained, but may be associated with subacromial crepitus. Smooth active motion is diminished, and symptoms are reproduced when the arm is lowered from an overhead position. Muscle weakness is related to the size of the tear and the muscles involved.
- 13. A subacromial injection of lidocaine may help to differentiate weakness that is caused by associated painful inflammation from that caused by a cuff tendon tear. Provocative manoeuvres including the Neer Impingement Sign and the Hawkins sign may be positive but are nonspecific because they may be positive with other conditions such as rotator cuff tendinitis, bursitis, or partial thickness rotator cuff tears. It is important that other potential etiologies be investigated. Patients with cervical radiculopathy at the C5-6 level can have an insidious onset of shoulder pain, rotator cuff weakness, and muscular atrophy in the supraspinatus and infraspinatus fossa.
- 15. PHASE 1: 0-4 WEEKS (MAXIMUM PROTECTION PHASE) 1. 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.
- 16. 2. Immobilization Brief sling immobilization for comfort only. 3. Pain Control Reduction of pain and discomfort is essential for recovery. Therapeutic modalities Ice, ultrasound, IFT. Moist heat before therapy, ice at end of session. Medications NSAIDs-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.
- 17. 4. SHOULDER MOTION a. Goals Internal and external rotation equal to contralateral side, with the arm positioned in less than 90 degrees of abduction. b. 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
- 18. Avoid assisted motion exercises Shoulder flexion. Shoulder extension. Internal and external rotation. Progress to active ROM exercises "Wall-walking“ 5. Elbow Motion Passive to active motion, progress as tolerated 0-130 degrees. Pronation to supination as tolerated. 6. Muscle Strengthening Grip strengthening (putty, Nerf ball, racquetball). Use of the arm for activities of daily living below shoulder level.
- 19. PHASE 2 : 4-8 WEEKS 1. Criteria for Progression to Phase 2 Minimal pain and tenderness. Improvement of passive ROM. Return of functional ROM. 2. Goals Improve shoulder complex strength, power, and endurance. 3. Restrictions Avoid provocative maneuvers or exercises that cause discomfort for the patient. Includes both ROM exercises and strengthening exercises. 4. Immobilization None.
- 20. 5. Pain Control Reduction of pain and discomfort is essential for recovery. Therapeutic modalities Ice, ultrasound, IFT Moist heat before therapy, ice at end of session. Medications NSAIDs Subacromial injection of corticosteroid and local anesthetic 6. Motion Goal Equal to contralateral shoulder in all planes of motion. Exercises Passive ROM. Capsular stretching. Active-assisted motion exercises. Active ROM exercises.
- 21. 7. 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 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.
- 22. Exercises are done through an arc of 45 degrees in each of the five clinical planes of motion. Six colour-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. 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.
- 23. Progress to light isotonic dumbbell exercises Internal rotation. External rotation. Abduction. Forward flexion. Extension. Strengthening of deltoid Strengthening of scapular stabilizers Closed-chain strengthening exercises Scapular retraction (rhomboids, middle trapezius). Scapular protraction (serratus anterior). Scapular depression (latissimus dorsi, trapezius, serratus anterior). Shoulder shrugs (upper trapezius). Progress to open-chain scapular stabilizer strengthening
- 24. PHASE 3: WEEKS 8-12 1. Criteria for Progression to Phase 3 Full painless ROM. No pain or tenderness with strengthening exercises. 2. 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. 3. Functional Strengthening Plyometric exercises
- 25. *Maximal improvement is expected by 4-6 months. 4. Progressive, Systematic Interval Program for Returning to Treatment of Warning Signals Sports Throwing athletes Tennis players Golfers 5. Warning Signals Loss of motion-especially internal rotation. Lack of strength progression- especially abduction, forward elevation. Continued pain-especially at night. 6. Treatment of Warning Signals 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.
- 27. INDICATIONS Partial or full thickness tears of rotator cuff as a result of repetitive microtrauma & chronic impingement which leads to irreversible degenerative changes in soft tissues. Some patients with stage II & most with stage III lesions who continue to be symptomatic and have functional limitations after 6 months-1 yr of non-operative treatment. Acute traumatic rupture of rotator cuff often combined with avulsion of GT, labral damage or acute dislocation of GH joint in individuals with no known history of RCI.
- 28. OPERATIVE PROCEDURE 1. Arthroscopic procedure – for small tears i.e. < 1-3 cm2. 2. Mini open procedure – incision along fibres of deltoid so that surgical space is more. 3. Open procedure – for massive tears, detach the proximal attachment of deltoid and then reattach after surgery
- 29. 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 non-dominant arm Preinjury level Desired level of function (work and sports) Work situation Patient compliance with therapy regimen Rehabilitation Situation Supervised or unsupervised Physician's Philosophic Approach
- 30. BASIC REHABILITATION GOALS AFTER ROTATOR CUFF REPAIR Goal 1: Maintain integrity of the repaired rotator cuff. Never overstress healing tissue. Goal 2: Re-establish full passive ROM as quickly and safely as possible. Goal 3: Re-establish dynamic humeral head control. Do not work through a shoulder shrug! Goal 4: Improve external rotation muscular strength. Re-establish 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.
- 32. PHASE 1: WEEKS 0 - 6 1. 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. Passive ROM only 140 degrees of forward flexion 40 degrees of external rotation 60-80 degrees of abduction without rotation
- 33. 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, non-smoker), 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. 2. 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 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.
- 34. 3. 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. Therapeutic modalities Ice, ultrasound, IFT, LASER. Moist heat before therapy, ice at end of session.
- 35. 4. Shoulder Motion Passive ROM 140 degrees of forward flexion. 40 degrees of external rotation. 60-80 degrees of abduction. For patients immobilized in abduction pillow, avoid adduction (i.e. bringing arm towards 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 5. Elbow Motion Passive-progress to active motion 0-130 degrees. Pronation and supination as tolerated. 6. Muscle Strengthening Grip strengthening only in this phase.
- 36. Phase 2: Weeks 6-12 1. 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. 2. 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. 3. Immobilization Discontinuation of sling or abduction orthosis. Use for comfort only.
- 37. 4. Pain Control NSAIDs for patients with persistent discomfort following surgery. Therapeutic modalities Ice, ultrasound, IFT Moist heat before therapy, ice at end of session. 5. 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. Exercises Continue with passive ROM exercises to achieve above goals Begin active-assisted ROM exercises for the above goals Progress to active ROM exercises as tolerated after full motion achieved with active-assisted exercises. Light passive stretching at end ROMs.
- 38. 6. Muscle Strengthening Begin rotator cuff and scapular stabilizer strengthening for small tears with excellent healing potential. Continue with grip strengthening
- 39. Phase 3: Months 4-6 1. Criteria for Progression to Phase 3 Painless active ROM. No shoulder pain or tenderness. Satisfactory clinical examination. 2. 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.
- 40. 3. Motion Achieve motion equal to contra lateral 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. 4. Muscle Strengthening Strengthening of the rotator cuff Begin with closed-chain isometric strengthening Internal rotation. External rotation. Abduction. Forward flexion. Extension.
- 41. 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. The arm should be comfortable at the patient's side. Exercises are performed through an arc of 45 degrees in each of the five planes of motion. 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.
- 42. Progress to light isotonic dumbbell exercises Strengthening of deltoid-especially anterior deltoid 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 (trapezius, levator scapulae). Progress to open-chain scapular stabilizer strengthening
- 43. 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 Progressive, systematic interval program for returning to sports Maximal Improvement Small tears- 4-6 months. Medium tears-6-8 months. Large and massive tears-8-12 months. Patients will continue to show improvement in strength and function for at least 12 months.
- 44. 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 May require repeat surgical intervention.
- 45. Indications for repeat surgical intervention Inability to establish more than 900 of forward elevation by 3 months. Steady progress interrupted by a traumatic event and/or painful pop during the healing phase with a lasting loss of previously gained active motion. Radiographic evidence of loosened intra-articular implants e.g. Corkscrew after an injury in the post-op period. The patient has a loss of active motion and/or crepitance of the joint as well.