Rehabilitation Rehabilitation Following Rotator Following Rotator Cuff RepairCuff Repair

Kolleen Shields MS, P.T. Kolleen Shields MS, P.T.

2006 Hawkeye Sports Medicine 2006 Hawkeye Sports Medicine SymposiumSymposium

TerminologyTerminology

Partial Rotator Cuff TearsPartial Rotator Cuff Tears

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

tendons)tendons)

Open Repairs vs. Open Repairs vs. ArthroscopicArthroscopic

Larger incisionLarger incision Deltoid Deltoid

detachmentdetachment More post-op More post-op

painpain Inpatient stay for Inpatient stay for

pain controlpain control

Smaller incisionSmaller incision Less post-op painLess post-op pain Outpatient Outpatient

procedureprocedure Pain is not a Pain is not a

good guide for good guide for rehabrehab

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

mobilitymobility

Immediate post-Immediate post-operative goals (0-2 operative goals (0-2 weeks)weeks) Control pain/swelling:Control pain/swelling:

– CryotherapyCryotherapy

(Speer et al. J Shoulder Elbow Surg. (Speer et al. J Shoulder Elbow Surg. 1996)1996)

– Medications as prescribedMedications as prescribed– Use of sling to limit shoulder Use of sling to limit shoulder

movementmovement– Sleep positionSleep position

Immediate post-Immediate post-operative goals (0-2 operative goals (0-2 weeks)weeks) Early protective passive motion:Early protective passive motion:

– PendulumsPendulums– Passive elevation (90-120 degrees)Passive elevation (90-120 degrees)– Table slidesTable slides– PulleysPulleys– Passive external rotation (0-20 Passive external rotation (0-20

degrees)degrees)– Elbow, wrist, hand active motionElbow, wrist, hand active motion– Isometric grip strengtheningIsometric grip strengthening– Periscapular isometricsPeriscapular isometrics

Early ROM ExercisesEarly ROM Exercises

Table SlidesTable Slides

Immediate post-Immediate post-operative precautionsoperative precautions Avoid extension movements Avoid extension movements

beyond plane of body (4 weeks)beyond plane of body (4 weeks) Avoid any active lifting of the arm Avoid any active lifting of the arm

(elevation/abduction: 6 weeks)(elevation/abduction: 6 weeks) Avoid active external rotation (4-6 Avoid active external rotation (4-6

weeks)weeks)

PosturePosture

Coracoacromial ligament and attachment to Coracoacromial ligament and attachment to acromion form a “roof” under which the acromion form a “roof” under which the supraspinatus tendon, the biceps tendon and supraspinatus tendon, the biceps tendon and subacromial bursa must pass during subacromial bursa must pass during elevation or abduction of the arm.elevation or abduction of the arm.

At approx. 70-120 deg of active At approx. 70-120 deg of active glenohumeral elevation, the greater glenohumeral elevation, the greater tuberosity approaches the “roof”tuberosity approaches the “roof”

Rounded shoulder posture narrows potential Rounded shoulder posture narrows potential space of the “roof,” thus making it more space of the “roof,” thus making it more likely that impingement may occur with likely that impingement may occur with elevation of the armelevation of the arm

Postural setsPostural sets

Progressive Progressive Rehabilitation (2-4 Rehabilitation (2-4 weeks)weeks) Continue pendulums and table slidesContinue pendulums and table slides Passive elevation (120-135 deg)Passive elevation (120-135 deg) Passive external rotation (20-35 deg)Passive external rotation (20-35 deg) Initiate pulleysInitiate pulleys

Tendon tissue healing requires the load Tendon tissue healing requires the load across the tendon to be minimal for the across the tendon to be minimal for the first 4 weeksfirst 4 weeks

Advanced passive Advanced passive motionmotion

Progressive Progressive Rehabilitation (4-6 Rehabilitation (4-6 weeks)weeks) Continue passive motion Continue passive motion

exercises (elevation:135-150 deg, exercises (elevation:135-150 deg, external rotation:30-45 deg)external rotation:30-45 deg)

Add bilateral extension motion Add bilateral extension motion with canewith cane

Add internal rotation for posterior Add internal rotation for posterior capsule stretch capsule stretch

Progressive Progressive Rehabilitation (6-8 Rehabilitation (6-8 weeks) A.A.R.O.Mweeks) A.A.R.O.M Gradually introduce controlled Gradually introduce controlled

stretches across the healing tendon stretches across the healing tendon during the maturation process. during the maturation process. Tissues need to see progressively Tissues need to see progressively increasing loads.increasing loads.

A.A.R.O.M for elevation: progression A.A.R.O.M for elevation: progression of wall walking, assisted supine cane of wall walking, assisted supine cane exercises, supine bilateral arm raiseexercises, supine bilateral arm raise

Assisted wall walkingAssisted wall walking

Progressive Progressive Rehabilitation (6-8 Rehabilitation (6-8 weeks) A.A.R.O.Mweeks) A.A.R.O.M

A.A.R.O.M for internal rotation: cane A.A.R.O.M for internal rotation: cane behind back, towel stretch, clasp hands behind back, towel stretch, clasp hands behind backbehind back

A.A.R.O.M diagonal supine with caneA.A.R.O.M diagonal supine with cane A.A.R.O.M extension standingA.A.R.O.M extension standing A.A.R.O.M for external rotation (35-55 A.A.R.O.M for external rotation (35-55

deg)deg) Continued wall walkingContinued wall walking Low level isometricsLow level isometrics

Progressive Progressive Rehabilitation (8-12 Rehabilitation (8-12 weeks)weeks) Continue with range of motion exercises Continue with range of motion exercises

working towards full functional mobility working towards full functional mobility (mobilization?)(mobilization?)

Should be able to raise arm above headShould be able to raise arm above head Add light resistance (cream/yellow) therabands: Add light resistance (cream/yellow) therabands:

– Bilateral extensionBilateral extension– Bilateral forward flexion (30 deg)Bilateral forward flexion (30 deg)– Bilateral external rotationBilateral external rotation– TricepsTriceps– Scapular retractionScapular retraction– Unilateral internal rotationUnilateral internal rotation– Abduction/AdductionAbduction/Adduction

Progressive Active Progressive Active ElevationElevation

IsometricsIsometrics

Active Assistive Range Active Assistive Range of Motionof Motion

Progressive TherabandProgressive Theraband

Progressive Progressive Rehabilitation (8-12 Rehabilitation (8-12 weeks)weeks) Side lying external rotation (light Side lying external rotation (light

weights) progressing from arm at weights) progressing from arm at side to arm away from sideside to arm away from side

Periscapular prone strengthening Periscapular prone strengthening with weightswith weights

Tricep strengthening Tricep strengthening Bicep curlsBicep curls

Periscapular Periscapular StrengtheningStrengthening

Side Lying External Side Lying External RotationRotation

Triceps/Biceps Triceps/Biceps StrengtheningStrengthening

Advanced Advanced Strengthening (12 Strengthening (12 weeks-6 months)weeks-6 months) Progression of theraband Progression of theraband

exercisesexercises Add closed chain exercisesAdd closed chain exercises PRE’s for external rotation, PRE’s for external rotation,

elevation, abductionelevation, abduction

Cuff Strengthening in Cuff Strengthening in AbductionAbduction

Progression of Progression of Active ExercisesActive Exercises

Progression of Progression of Stabilization ExercisesStabilization Exercises

Highest Level Highest Level Strengthening May Strengthening May IncludeInclude ““Full” range strengthening Full” range strengthening

activitiesactivities Body bladeBody blade Therapeutic ball activitiesTherapeutic ball activities Plyometric activitiesPlyometric activities Return to sport drillsReturn to sport drills

Full Range Full Range StrengtheningStrengthening

Therapuetic Ball Therapuetic Ball ExercisesExercises

Body BladeBody Blade

PlyometricsPlyometrics

Rehabilitation Rehabilitation Following Rotator Cuff Following Rotator Cuff TearsTears

Initial GoalsInitial Goals

Control pain (cryotheraphy, Control pain (cryotheraphy, medication, sling)medication, sling)

Begin gentle, passive/active Begin gentle, passive/active assistive range of motion assistive range of motion exercisesexercises

Sleep positionSleep position Rest armRest arm

Goals of Therapeutic Goals of Therapeutic ExerciseExercise Improve strength of surrounding Improve strength of surrounding

musculature in order to regain musculature in order to regain functional use of the armfunctional use of the arm

Proceed slowly and use pain as a Proceed slowly and use pain as a guide.guide.

Partial RCT can progress to full Partial RCT can progress to full thickness tears. thickness tears.

Return to functionReturn to function