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Rotator Cuff Arthropathy. Andre Le Leu Physiotherapy Clinical Specialist Shoulder and Elbow Unit Stanmore, UK. Contents. Anatomy Pathology Sub-acromial Impingement Syndrome Clinical Assessment Treatment methodology. Anatomy. Anatomy. Acromium. Rotator interval. Supraspinatus. - PowerPoint PPT Presentation
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Rotator Cuff Arthropathy
Andre Le LeuPhysiotherapy Clinical Specialist
Shoulder and Elbow UnitStanmore, UK
Contents
• Anatomy• Pathology• Sub-acromial Impingement Syndrome• Clinical Assessment• Treatment methodology
Anatomy
Anatomy
Subscapularis
Corocoid
Rotator interval
Acromium
Supraspinatus
Infraspinatus
Teres minor
Glenoid
AnteriorZone
Posterior/SuperiorZone
NB: Subacromial Bursa not illustrated here but a critical element
Biomechanical Considerations
Suprasp.
Infraspin
Subscap
Teres Minor
Deltoid
Cable Theory
Anterior Pillar Posterior Pillar
subscap
LHBT Supra/infra sp.
Teres Minor
Rotator Cuff Tendonopathy40 yrs 60 yrs 80 yrs +50 yrs
‘Repetitive strain’ overuseBiomechanical impingementAngiogenesisUp regulation of fibroblast activity
PHYSIOTHERAPY +++++++
Intra-substance tearsPlasma enrichmentSurgical debridement
PHYSIOTHERAPY +++
Rotator cuff tearsRehab Surgery
GENTLE PHYSIOTHERAPY
Salvage opsTendon transfersConstrained TSR
FUNCTIONAL REHAB
Rotator Cuff Examination
• No test is absolute and definitive • Tests are merely a provocation symptoms
rather than a confirmation of diagnosis (Lewis, 2008)
• 90% of diagnoses are made from the patient history (Malone, 2005)
Examination
• Look…. Postural alignment
Bony landmarksMuscle bulk/atrophyGeneral (scars, limb perfusion etc)
• Feel….Palpation (joint lines, muscle belly, ligaments/bursa)
• Move….Active movement, passive movement, resistance
DO NOT FORGET NEUROVASULAR COMPONENTS / CLEARING TESTS
Special Tests
• Supraspinatus– Jobes Test 90 degrees scaption
Internal rotation (thumb down) Without resistance then with resistance Pain and or weakness
Modification to start in thumbs up and run resistance testing through range to include rotator interval component.
- Initiation of Abduction testing Arm by the patients side Palpate the Humeral Head Assess resisted abduction Weakness, pain, superior translation of humeral head are all indicative of a positive test
Subscapularis• Gerber’s Lag sign
As above but the therapist positions the hand ways from the spine and the patient must hold this position. (80% sensitivity for small tears)
• Gerber’s lift off testHand behind the back at 90 degrees elbow flexionThe patient must keep the arm away from the spineThe Therapist can add resistance (90% sensitivity for weakness or pain)
• LaFosse belly press Hand rests on belly with wrist at neutral away from the forearm Held away from the body. The patient pulls the entire arm into the stomach (watch for drop of elbow or wrist),
can also add therapist resistance to the outside of the elbow Good for patients with restrictions to movement Recruitment of P.major in 25% clouds the examination
Infraspinatus and Teres Minor
• Resisted testing1. External rot lag sign (ERLS) with arm at waist the
therapist positions arm in full external rotation and the lets go while the patients attempts to hold this position. You can then add therapist resistance and required looking for pain/weakness.
2. Patient Holds arms in 60 degrees scaption with elbows at 90 degrees. Patient must resist internal rotation movement against the therapist.
Pain and or weakness can be indicative of posterior cuff insufficency.
Infraspinatus and Teres Minor• Patte’s Test
90 degrees of abduction and external rotation, the patient must hold against resistance.
Watch for correct scapulo-thoracic alignment Can test eccentric control element
• Hornblowers Sign Arm held in 90 degrees scaption with hand in front of the mouth (supination).
Patient must move the arm out into external rotation against gravity, however the therapist can also look to add resistance.
• Hornblowers lag sign Arm is positioned at 90 degrees in scaption with full external rotation by the
therapist. The Patient must the hold this position once the therapist lets the arm go. A positive drop sign is indicative of a massive posterior cuff tear.
Biceps tendon• Check for Popeye sign (rupture of LBHT)• Speeds test
Patient holds straight arm in supination at 90 degrees flexion and tries to elevate the arm against the therapists resistance. Pain indicative of provocation.
90% Sensitivity and 15 % specificity (Malone 2005)
• LaFosse AERS test (abduction, ext rot, supination) Arm is held at 90 degrees abduction and externally rotated with elbow at 90
degrees in pronation. The Therapist provides resistance as the patient supinates the arm Pain is indication of possible biceps irritation or SLAP tear
• Yergason’s test – arm by side and elbow at 90 degrees, the therapist holds the patients hand and resists
the patient moving into supination while palpating the LHBT. – Look for pain and or subluxation of tendon from bicepital groove
Shoulder Impingement Syndrome
Impingement Tests
• Neer’s Test– Therapist stands behind the patient and stabilizes the scapular. The
holds the arm in ‘thumbs down’ in full elbow extension. – The maneuver is to the elevate the arm into f.flexion– Provocation of pain (80% specificity for bursa and cuff problems
Malone et al)
• Hawkins (Kennedy) Test– Therapist holds he arm in the plane of the scapular with the elbow at
90 degrees.– The hand is put into a thumbs down position and then the arm is
medially rotated, a positive test provokes pain/restriction of movement (90% sensitivity, Malone et al)
Acromioclavicular joint
• Pain on palpation • Pain at end range abduction, hand behind
back• Scarf test
» Pain provocation with horizontal adduction» NB restriction of movement may be due to posterior
capsular stiffness esp. if scapular is held in retraction
Innervation• Suprascapular nerve
• Nerve to Subscapularis
• Axillary or Circumflex nerve
• Lateral Pectoral Nerve
• Autonomic Nervous System (LBHT)
Practical Session
• Basic Assessment
• Provocation Testing
• Where to Start Rehab?
Indications forShoulder Replacement Surgery
Indications for surgery
• Pain• Loss of function and ROM• Quality of life• Failed conservative management• Age related considerations
Indications for Primary TSR
Neer Classification System for proximal humeral fractures
Pathology
AVN Tumours
Infection
Types of Shoulder Prosthesis• Fully constrained = For severe arthritis of the shoulder
and destruction of the rotator cuff. Basically a salvage procedure.
• Semi constrained = To prevent superior subluxation of the humeral prosthesis when the patient has joint arthritis and rotator cuff insufficiency.
• Un Constrained =Joint arthritis with good rotator cuff function.
• Surface replacement= one articular surface involved
Cemented or Uncemented?
Cemented• Reduced pain reported
• Increased mobility
• Senior population
• Less physically demanding lifestyle
Uncemented• Avoid loosening of parts
• Scope for revision in younger person
• Active lifestyle
• Extended recovery period
RNOH Philosophy
• Bone Stock & Rotator Cuff
– Good BS / good RC = unconstrained TSR
– Good BS / poor RC = Constrained
– Poor BS / good RC = CAD-CAM stem
– Poor BS / poor RC = CAD-CAM glenoid/stem
Surface Replacement
Unconstrained
Modular (no glenoid liner)
Cemented or uncemented
Sulzar TSR – with glenoid liner (cemented)
Glenoid screw and Biomet Humeral Component
Constrained
Reverse Delta-3
Constrained
Reverse Fixed Fulcrum (Bayley-Walker)
Constrained
CAD CAM
RNOH Rehabilitation guidelines
Weak and smooth shoulderStiff shoulder
Post operation immobilisation
Abduction pillow polysling
Rehab Guidelines All of this will vary according to the individual
Phase 1 – Initial RehabOptimise tissue healing (time specified)
Pain control “SMOOTH AND WEAK”Use of slingNo ER>neutral/20 degreesA-A/Passive elevation<90 degreesNo active use of UL or strengtheningNo HBB or cross bodyEducation
Milestones for next stageAchieved time specific goalsFor X-rays to show osseo-integrationAllowed ROM achievedReduced painAdequate scapula control
Early phase day 1 -6/52 exercise
Active assisted GHJ FF 90 ISOMETRIC ER IN NEUTRAL
ISOMETRIC IR IN NEUTRAL Carer performing the exercise
Early phase day 1 -6/52 exercise
Start position with shoulder supported
Active assisted GHJ ER to neutral start…
Carer performing the exercise
End position of exercise
Phase 2 – Early Recovery (approx 6 weeks – 4 months)Decrease sling use
Start light activity at waist level
Increase ROM
Optimise normal movement patterns
No exercises that increase pain
No active anti-gravity work until RC rehabilitated
Deltoid Programme for Constrained TSR
Milestones for next stageNo sling
Minimal pain
Passive ROM: elevation>90 and ER>30
RC stabilises within available ROM
Functional Triangle
Phase 3 – Late Recovery (approx 5 months – 12 months)Increase strength and endurance to functional level required
No exercises that increase pain
No heavy lifting above shoulder level
Milestones for DischargeReduced pain from pre-op status
Achieved functional goals
Expected outcomes Unconstrained – Light to moderate use at waist, shoulder and above shoulder level
Constrained – Light use at waist level and
towards shoulder height if possible
May take 12-24 months to achieve
Rehabilitation Guidelines
• www.rnoh.nhs.uk• Follow link to CLINICAL SERVICES• Click on Physiotherapy• Click on SHOULDER AND ELBOW UNIT• Select Guideline for exercise information
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