Rotator Cuff - Post Operative Management Edit 0 123 …

Table of Contents1. Management of Rotator Cuff Tears2. Medical Management2.1 Prevalence of Rotator Cuff Repair2.2 Rotator Cuff Repair Options2.3 Pharmacology2.4 Standard Post-Op Imaging2.5 Surgical Complications2.6 Surgical Management for Re-Tear of Rotator Cuff Repair3. Patient Examination/Evaluation Following Surgery3.1 Questions to Ask3.2 Observation3.3 Active & Passive ROM3.4 Manual Muscle Test4. Physical Therapy Management4.1 Outline and Goals4.2 Treatment PlanPhase I (0-4 weeks)Phase II (4-6 weeks) Perfect FitPhase IV (8-12 weeks) Perfect FitPhase V (3 months+) Perfect Fit5. Current Research6. Resources7. Patient Perspectives8. References

1. Management of Rotator Cuff Tears

Treatment options include conservative management and surgical repair The treatment of rotator cuff tears depends upon several factors including:o Duration of symptomso Shoulder dominanceo The type of tear (partial vs. full thickness)o Patient factors such as age, comorbidities, and activity level 1 Few randomized clinical trials have been performed that directly compare surgical and conservative

management of rotator cuff tears 1 A trial of conservative management, mainly consisting of physical therapy, is generally indicated firsto See Conservative Physical Therapy Management Section of Rotator Cuff Pathology Pageo If conservative management is unsuccessful in relieving pain or improving function, surgery may be

required The exception for beginning with conservative treatment first is if a patient suffers an acute, full thickness

traumatic rotator cuff tearo Patients should immediately be treated via surgical repair as a delay in surgical intervention can lead to

significant muscle atrophy, tendon retraction, and poor surgical results 2

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2. Medical Management

2.1 Prevalence of Rotator Cuff Repair

Approximately 250,000 - 400,000 rotator cuff procedures are performed annually in the United States6

The unadjusted volume of all rotator cuff repairs increased 141% between 1996 to 20067

o Arthroscopic repairs increased by 600%o Open repairs increased by 34%o Study performed in Finland between years of 1998 to 2011 showed similar increases in incidence5

Mini-open repairs are reportedly the most frequently used method of repair followed by open repairs, then arthroscopic repairs7

2.2 Rotator Cuff Repair Options

Goals of Rotator Cuff Repairo Eliminate pain and improve functiono “Optimal repair of the rotator cuff includes achievement of high fixation strength, minimal gap formation

and maintenance of mechanical stability under cyclic loading, and proper healing of tendon to bone”3

General Repair Approach4

o Re-attaching tendon to boneo Utilization of suture anchorso Attaching sutures to the anchors in order to tie tendon down to bone

Three Most Common Forms of Rotator Cuff Repair3,4,5,6

Open Repair Mini-open All-arthroscopic

Description Meticulous repair of deltoid origin, subacromial decompression, surgical releases as necessary, secure transosseus fixation of tendon to tuberosity; 3-6 cm incision made over anterior-superior aspect of shoulder; deltoid is taken off anterior aspect of acromion and split laterally

Arthroscopy used to perform a subacromial decompression and avoid deltoid removal; deltoid fibers split in line to allow access to secure bone-tendon fixation; debridement of tendon edges, releases, mobilization, and single-row anchor placement can be done arthroscopically; 3-4 cm incision size

1-3 small incisions for insertion of several cannulas; 1 cm incision; tendon-bone fixations with single or double row of anchors or with transosseus technique

Indications Large or massive tears; when quality of remaining tissue is poor, significant tendon retractions and adhesions are present; when additional reconstruction is necessary

Advantages High satisfaction rates; allow for easier transosseous fixation to better replicate the footprint of the supraspinatus tendon and may provide a better potential for healing; Use of a modified Mason-Allen stitch, which is stronger in comparison to a simple stitch

Minimized deltoid injury; moderate post-op pain

Least invasive; lower risk of complications like stiffness, infection, and deltoid avulsions; minimal deltoid involvement; less immediate post-operative pain

DisadvantagesLoss of anterior deltoid a possible complication; deltoid removal requires protection for at least 4 weeks post-op; increased pain

Lack of long-term data; technical difficulty; controvery over optimal fixation method

Outcomes Good to excellent results in functional improvement (75-95% of patients) and pain relief (85-100% of patients); tear-size most important determinant for active motion, strength, satisfaction, and need for reoperation

Similar to open-repair; 80-88% of patients have good to excellent results long term

Due to the advancement of surgical techniques, a "gold standard" no longer exists for rotator cuff repairs7

Arthroscopic and open repairs have comparable clinical results7

The smaller the injury tear, the more likely surgical repair will be successful8

2.3 Pharmacology

Interventions

Zolpidermo The use of Zolpidem for analgesia after arthroscopic rotator cuff repair provided a significant reduction in

the need for rescue analgesic without increasing adverse effects 23o Mean VAS pain scores during the first 5 days after surgery did not differ between the Zolpidem group and

the control group Anti-adhesive agent injectiono The injection group showed faster recovery of forward flexion at 2 weeks postoperatively than the control

group but the difference was not statistically significanto A subacromial injection of an anti-adhesive agent after arthroscopic rotator cuff repair tended to produce

faster recovery in forward flexion with no adverse effects on cuff healing 24

Superficial Infection

Antibiotics should be directed at the most commonly isolated bacteria: Staph aureus, Staph epiderrmidis, Propionibacterium acnes, and Corynebacterium species

Surgical preparation solutions have been tested against these common bacteria and although no significant difference was found in the ability to eliminate P. acnes, ChloraPrep was found to be more effective than DuraPrep or povidone-iodine at eliminating coagulase-negative Staphylococcus

In another study, 4% chlorhexidine gluconate was also shown to have significantly lower bacterial colonization and postoperative wound infections compared to povidone-iodine, although no mention of P. acneswas made in this study 22

Venous Thromboembolism 21

Once diagnosed, postoperative VTE's are generally treated with anticoagulation medication for at least 3 months

2.4 Standard Post-Op Imaging

Fracture (rare) 20

Can be evaluated with radiography in patients who sustain a trauma after their rotator cuff repair and complain of pain and/or limited motion

CT scan will help delineate the pattern and displacement of the fracture in order to help dictate management

Nerve Injury 18

Electromyelography (EMG) often recommended at 3-month mark if normalization of nerve deficit has not occured

A brachial plexus specialty clinic reviewed all cases over a 10-year period and found 26 patients with iatrogenic nerve injuries from periods shoulder surgery -- both open and arthroscopic procedures

2.5 Surgical Complications

Nerve injury Infection Stiffness Re-tear 9o More likely to occur in patients that have the following:8

Large (3-5 cm) or massive tear (>5 cm or 2 tendon) Previously failed rotator cuff surgery at the same site Chronic tear Adhesive Capsulitis 17o High post-op stiffness requires subsequent surgeryo Both ROM and objective outcomes increased after surgery Superficial Infection 19

o If there is a concern for deep contamination, then a formal surgical irrigation and debridement may be warranted

o Failure of symptoms to fully resolve after a course of oral antibiotics should be considered to be indicative of deep infection, and at that point, operative treatment should be performed

Fractureo Patients may need open reduction internal fixation (ORIF)

2.6 Surgical Management for Re-Tear of Rotator Cuff Repair

Revised Rotator Cuff Repair

Up to 50% of revised rotator cuff repairs remain intact at 1 year post-op and improvements in pain and outcome scores are observed 10, 11

Complications are twice as common with revisions compared to primary rotator cuff repairs Factors to take into account:o Patient factors  symptoms, functional losses, medical history, and previous surgeries 14o Anatomic factors  acromiohumeral interval, presence of fatty infiltration, size and characteristic of tear,

quality of tendon, and concomitant pathology

Other Options

When a rotator cuff repair fails and both the surgeon and the patient agree to surgical management, there are several options of treatment available besides a revision repair including scaffold augmentation, tendon transfer, or reverse shoulder arthroplasty (RSA)

o Scaffold Augmentation  12 13 Rotator cuff repair tears are irreparable if the native tendon cannot be mobilized and repaired to the bone;

or the muscle is no longer functional due to fatty infiltration Use of patient's own tissue; Scaffolds are designed to augment or bridge the muscle-tendon-bone unit

and eventually incorporate into the host tissue This is a proposed idea --> much of the current evidence consists of technique articles or short-term

follow up with no control group. There is currently not enough evidence in the literature to analyze the results of scaffold augmentation to failed rotator cuff repairs specifically.

o Tendon Transfer   14   15 Often utilized in younger and more active patients that are not willing to comply with the life-long activity

restrictions of constrained shoulder arthroplasty Most common = Latissimus Dorsi transfer Restores function, AROM, strength, and pain relief in patients with posterosuperior rotator cuff tears Poor results in patients with Subscapularis insufficient and Teres Minor fatty infiltration Trapezius transfer used to restore external rotationo Reverse Shoulder Arthroplasty (RSA)   16 Treatment for rotator cuff failure after a prior rotator cuff repair Treatment of painful and dysfunctional rotator cuff-deficient shoulders Patients with pseudoparalysis (less than 90 degrees of active forward elevation, but still have full passive

elevation): RSA can achieve excellent pain relief and restoration of function

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3. Patient Examination/Evaluation Following Surgery

3.1 Questions to Ask

Have you had any flu-like symptoms since your surgery?

Important to screen for possible infection post-surgery

What was your prior level of function? Were you working or playing sports?

Important for goal setting & assessing activity level Make sure to screen for yellow flagso Malingering behavior can delay outcomes of rehab 27

What is the level of your pain? Where is the majority of your pain located?

Factors that contribute to pain:o Severity of Tear 25o Patients who note self-reported high pain tolerances display the highest level of acute pain after

arthroscopic rotator cuff surgery 28o Narcotic use, smokers, and younger patients were also predictive of higher pain levels during the first

post-operative week 28

When was the surgical procedure performed?

May give you an idea of status of tissue healing 29o Inflammatory: 1st week; platelet and fibroblast accumulationo Proliferation: first 2-3 weeks; forming type III collageno Remodeling: begins 3-4 weeks; transition from type II to type I collagen fiber formation; scar tissue

formationo Full Tensile Strength: not reached until 12-16 weeks post-op

What activities have you been doing to help with managing pain & range of motion?

Will provide patient's level of activity/sedentary behavior Make sure to screen for yellow flag behavior:o Fear avoidance: patient may not have moved shoulder at all since surgery - more stiff presentationo Overly ambitious/impatient to rehabilitative process - may move their shoulder on their own more than

what is permitted by the physician

What are your lifestyle habits? Any current or previous history of drug use, age, activity level, or prior injuries?

Factors that can inhibit rehabilitation process: 30o Rotator cuff was already torn or weak before the injuryo Larger tearso After-surgery exercise and instructions are not followedo Older patients (over 65)o Smokingo Narcotic use

What are your goals for therapy?

Patient may have failed conservative approach for injury prior to surgery Address prior level of function

3.2 Observation

Examine patient's shoulder for any potential swelling, redness, warmth, or lesions to the skino Patient will be wearing a sling Provides stabilization/immobilization for approximately 4-6 weeks prior to their initiation of therapy 25 26o Patient could present with swelling in the shouldero Redness & warmth around incision site should not be presento Incision sites can differ based on the surgical procedure chosen

3.3 Active & Passive ROM

Active ROM

Will not be formally assessed until AROM phase begins to allow for tendon healing

Passive ROM

Assess patient's shoulder ROM in supine with flexion, abduction, external rotation, & internal rotationo Patient should present with a normal end feel with pain at end range of motion 25o Slight shoulder stiffness can also be present due to lack of mobility following surgery 25o Instructed by physician to perform basic passive range of motion exercises starting as early as the day of

surgery 26

3.4 Manual Muscle Test

Will not be formally assessed until strengthening phase begins

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4. Physical Therapy Management

4.1 Outline and GoalsIn the last decade, the availability of additional evidence based research on tissue healing, re-tear rates, and patient outcomes have increased the use of more conservative protocols by many clinicians. Evidence suggests that aggressive early phase rehabilitation does not significantly improve overall patient outcomes such as pain, ROM, strength, and function while carrying an increased risk for re-tears, particularly in those with large pre-operative RTC tears and/or poor tissue quality. 31 32 33 Additionally, the increased use of arthroscopic techniques have resulted in less post-operative stiffness. 

As a patient moves through protocol phases, the repaired rotator cuff is progressively loaded with the introduction of new exercises and resistance modifications to exercises from previous phases. This is based on studies analyzing specific muscle activation through the use of electromyography (EMG). Exercises resulting minimal EMG activity of the involved rotator cuff muscles are preferred in the early phases of rehabilitation in order to promote increases in range of motion while protecting the integrity of the repair. Conversely, exercises resulting in higher EMG activity are appropriate later on in the strengthening phases. 34 35 36 In general, progressing through phases is time gated and influenced by tissue healing mechanics, pain, range of motion, and strength goals. 

A general outline of the progression during therapy is:

1. Immobilization and protection of the tissue2. Restoration of range of motion while minimizing stiffness3. Strengthening4. Return to sport/activity

General strengthening progression (Submax -> Max):

1. Isometrics2. Progressive resistance exercises3. Stabilization exercises4. Functional / Sport specific

4.2 Treatment PlanThe following is a suggested treatment plan. 29 It is important to note that for optimal results, post–operative management and rehabilitation following rotator cuff repair should be individualized and modified based on the tear size, tissue quality, method of fixation, involvement and repair of additional

structures, and other pathology. Sling/immobilizer use should be outlined by the surgeon and its continuous use outside of therapy sessions typically lasts 4-6 weeks. Additionally, abduction pillows may be used during a portion of the sling phase to decrease compression of the supraspinatus across the humeral head and increase vascularity. 37

Phase I (0-4 weeks)Goals

Control inflammation and pain

Therapeutic Exercises

Codman's pendulum exercises Painless PROM in all planes in the supine position No AROM

Phase II (4-6 weeks) Perfect FitCriteria

Pain-free passive forward flexion to 120 degrees, passive external rotation to 45 degrees at the side and in 90 degrees of abduction, passive internal rotation to buttock

Goals

Full, painless PROM

Therapeutic Exercises

Continue to progress with PROM in all planes in the supine position Elbow and wrist ROM exercises with glenohumeral joint supported Sidelying scapular protraction/retraction to encourage serratus anterior and lower trapezius activation Gentle scapular/glenohumeral joint mobilization to regain full PROM

Phase III (6-8 weeks) Perfect FitCriteria

Full PROM

Goals

Progress with AAROM

Therapeutic Exercise

AAROM in the supine position AAROM with wall crawls Aqua therapy to progress with AAROM Submaximal shoulder isometrics

Phase IV (8-12 weeks) Perfect FitCriteria

Full, painless PROM Full AAROM in forward flexion in the supine position

Goals

Full AROM in all planes Maintain full PROM Optimize neuromuscular control

Therapeutic Exercises

Initiate AROM in all planes Shoulder isometrics in all planes Initiate strengthening program only after patient can elevate arm in the scapular plane without shoulder or

scapular hiking Light strengthening with in all planes <5 pounds - begin with tubing and progress to hand weights External /Internal rotation with sport tubing (Theraband) Full can in scapular plane (avoid empty can at all times)

Phase V (3 months+) Perfect FitCriteria

Full, painless PROM and AROM in all planes Able to tolerate progression to low-level functional activities

Goals

Maintain full PROM and AROM Progress with stretching and strengthening Return to sports at 5-6 months given proper benchmarks met

Therapeutic Exercises

Continue stretching and ROM as needed Advance proprioceptive and neuromuscular activities with perturbations, body blade, wall ball Addition of strengthening with multiplanar motion in functional proprioceptive neuromuscular facilitation

(PNF) patterns

Return to Sport

May return to sports that require overhead activity at 5-6 months when ROM is symmetric and painless and strength is 90% of contralateral side

Begin with submaximal sport specific/functional exercises Progression should include periodization and varied regimens between sessions for optimal results

Joint MobilizationsGlenohumeral and scapulothoracic joint mobilizations may be performed throughout the rehabilitation process with the goal of increasing ROM. They should be performed taking tissue healing, protocol restrictions, and patient tolerance into account.

Additional PrecautionsWhen adjacent structures are surgically repaired in addition to the rotator cuff, additional precautions may be added to the rehabilitation protocol. These following are an example of clinician recommended precautions for rehab when RTC and additional structures are surgically repaired:

Rotator cuff repair with biceps tenodesis (2 weeks post-op)

o No active flexion/extension of the elbow Rotator cuff repair with Subscapularis repair (6 weeks post-op)o No ER past 35 degreeso No adduction past midlineo No active IR or IR behind the backo No supporting of body weight on affected side

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5. Current ResearchA Comparison of Rehabilitation Methods After Arthroscopic Rotator Cuff Repair: A Systematic Review. 38.

Disclaimer:Due to the delayed release (embargo) of the article at the time of viewing, I was only able to gain access to the abstract of the article.Level 2 evidence; Systematic ReviewThis review looked at different rehabiltation protocols post arthroscopic rotator cuff repair. The researchers found studies conducted on comparing early versus late mobilization and continuous passive motion(CPM) verses manual therapy approaches. Only level 1 and 2 evidence was included in this systematic review. Upon review of the finally agreed upon 7 articles, the researchers found that the current data does not show a significant difference between the effect of timing of mobilization and use of CPM.This article will be released to the public in july of 2016http://www-ncbi-nlm-nih-gov.pitt.idm.oclc.org/pmc/articles/pmid/26137178/

Early Versus Delayed Passive Range of Motion After Rotator Cuff Repair: A Systematic Review and Meta-analysis. 39.

The purpose of this study was to look at the effects of early vs. delayed passive range of motion on retear rates after rotator cuff repair. In the first analysis of current evidence that was conducted, which looked at only level 1 studies, did not reveal a significant difference between the timing of PROM use in post op rehab. The second analysis, which included level 1-4 studies showed a significant difference of about 30% higher retear rates with early PROM versus delayed, especially when looking at double row anchor repairs. This study is significant in showing that as of 2014, the authors were unable to ascertain more high level evidence to state the detrimental effects of early passive range of motion, but it can be deduced from this study that the size of the tear can have a significant impact on post op rehab.

The influence of intra-operative factors and postoperative rehabilitation compliance on the integrity of the rotator cuff after arthroscopic repair. 40.

This study from 2015 further looked at the predisposing factors of supraspinatus and infraspinatus retears after surgery. Functional outcomes were determined using the Constant score, the Oxford Score, and the Western Ontario Rotator Cuff Index. In the research conducted, the researchers found that in the subjects (mostly older adults) that participated had a significantly higher retear rate in the first 12 weeks than in the second 12 weeks. That is 25% in the first versus the 4% in the second. That said, it was also determined that patient compliance was a prognostic factor for re-tearing along with the size and extent of the original damage, integrity of the tissue, and quality of the repair performed. Highest patient non-compliance (20%) was noted during the second 6 week time frame.

Are delayed operations effective for patients with rotator cuff tears and concomitant stiffness? An analysis of immediate versus delayed surgery on outcomes. 41.

Level 2 evidence: prospective comparative study from 2015The purpose of this study was to look at the immediate rotator cuff repair with capsular release versus rotator cuff repairs performed after rehabilitative therapy. The researchers that conducted this study found that at a mean follow-up period of about 22 months, they found no significant difference between the two approaches. They recommend treating the tear surgically with capsular release to save time and to avoid unnecessary preoperative rehabilitation.

Early mobilization following mini-open rotator cuff repair: a randomized control trial. 42.

This study looked at the clinical outcomes of early mobilization versus post op immobilization for 6 weeks in a mini-open rotator cuff repair. There were 189 subjects that were followed up to 24 months post op. The researchers found that even though at 6 weeks the mobilization group had significantly increased abduction and scapular elevation, that at the 24 month mark, no significant differences were found between groups. They recommend the choice of these two protocols after surgery be left up to the discretion of the patient and the surgeon.

Delayed early passive motion is harmless to shoulder rotator cuff healing in a rabbit model. 43.Controlled laboratory study published in 2013The study looked at immediate postoperative continuous immobilization, versus nonimmobilization versus immobilization with early passive motion in 90 New Zealand White Rabbits. The researchers hoped to answer if postoperative early passive motion could be supported by laboratory evidence.They used a histological study to determine that there was better healing post op in both the immobilization and immobilization with early passive motion groups than in the non immobilization group. Furthermore, the study help to show that immediate immobilization let to better healing than immediate mobilization. Keep in mind that the 12 weeks at most follow up could be a significant limitation to this study. The researchers also determined that early passive motion was harmless in tendon-bone healing.

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6. ResourcesGeneral Shoulder Overview for Physical Therapists

https://youtu.be/jc_Gh0738Bw

Referenced Article:Vascularity and tendon pathology in the rotator cuff: a review of literature and implications for rehabilitation and surgery. 37.

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7. Patient Perspectives

Patient Perspective.pdf

Details Download 384 KB

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