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UQ 1
RCT
| Question | Answer |
|---|---|
| What is the percentage of RCT for: 40-49 yrs old 50-60 >70 | 25% 33% cadavers 100% cadavesrs |
| What is the % in the general population of : -Full thickness tear -Partial Thickness tear Are these tear mostly asymptomatic or symptomatic? | Full: 7-27% Partial 13-37% Asymptomatic 34% out of 96 pileWhat |
| What can RCT be associated with? | smoking repeated steroid injections systemic disease: -RA -Gout neurogenic disorder |
| What factor has a role, in the development and progression of full-thickness RCT? | Genetic FactorWhat |
| What is the failure rate of repair outcomes? Generally accepted Rate? | 90% 25-40% |
| How long does it take an asymptomatic tear to become symptomatic? | 2.8 yrs high correlation of advance age and tear |
| Who typically does better post -op repair? who does worse? | Better: ppl who thought they would do good Worse: pple who thought poorly of outcome & workers comp |
| Who had higher expectation for post-op? | occupation (employed) Doctor gave information poorer pre-op fxn |
| Who had higher concern: | decreased physical health decreased mental health |
| Post-op rehab has gradually changed bc of an emphasis on what? what was this due to? | immediate motion muscle activation restricted fxn activités -surgical technique |
| What are the primary goals of surgery/Rehab? | Restore fxn abilities of the UE 1. maintain integrity 2. reduce pain, mm inhibition 3. re-establish passive mobility 4. re-establish mm balance/ motor control |
| What are the critical factor to consider before beginning Rehab? | Epidemiological factor influencing surgery & rehab of RCT Type of repair tissue quality size of tear number of tendon age and tear size other pathologies location of tear (which mm were involved) |
| Types of Repair | Deltoid split -open vs mini Deltoid take down Arthroscopy |
| Soft tissue integrity Osseous Tissue Integrity | mm bony |
| Bicep and AC jt pathology increase risk of what by 11 times that with out associated injury? | poor tendon healing |
| How often is there an isolated supraspinatus tear? | 50% of time |
| Location of tear 58-80% continue where? what occurs moderate frequency | posteriorly from supra into infra anterior extension into subscap |
| Size di not effect the outcome if surgery was before how many months what had worse outcomes? | 4 massive repair >4 months |
| What % was the mechanism of failure traumatic | 3-5% |
| What surrounding tissue quality is important for force coupling | integrity of : -infra-teres minor-subscap |
| How long will the pt be in a sling | 8wks immobilization |
| how long may it take for improvement in pain and fan how long to feel comfortable | may take a year 6 months |
| Fatty infiltration is reversible (true or false) | false |
| What can occur even after an adequate repair bc of the direct post-op tx | shoulder stiffness (you panic & stretch harder to mobilize and it hurts them more) |
| What are the 4 types of tear | 1. bursal side partial-thickness 2. mid-substance 3. articular side 4.full-thickness tear |
| what type of tear occurs more often at the musculo-tendinous junction | bursal side partial thickness tear |
| Partial thickness tears can occur where from what? | 1.superficial fibers from the coracohumeral log 2 superficial fiber in the supraspinatus and infra 3 deeper fibers of subscap and infra 4 deep extension of CH log (true jt capsule) |
| in the middle of the mm tear | mid substance tear |
| type of tear often see at the insertion site where vascularity & sensation may be less than that of burial side tears (may explain pn after debridement and SAD) | Articular side tear |
| Pt may relate their pn to a recent event w/ continued ???ing you may find a previous previous hx of shldr pn this recent event may be the "straw that broke the camels back" | acute extension of a tear |
| classify tear size small: medium large massive | less than 1 cm 1-3 cm 3-5cm >5 |
| what is the hallmark sign of RCT | night time pain |
| what is the physical presentation of RCT | atrophy, depending on chronicicity of a tear tenderness along tuberosities and AC jt full thickness you could palpate crepitus w/ elevation |
| ROM with a RCT | PROM generally greater than active loss of AROM |
| weakness of ER w/out pn sign of | non-reactive full-thickness tear |
| weakness with pn may indicate | reactive full-thickness tear or partial thickness tear |
| how do partial or slpit thickness tear generally occur | overuse |
| what type of surgery for small tear <1cm population they occur | arthroscopically (may require deltoid splitting -decreases recovering time bc deltoid is not taken down occurs in middle aged |
| more recently done arthroscopically may require deltoid to be take down tear can be more perpendicular to line of contraction of RTC more protection during healing 3wks for soft tissue 6 weeks for maturation of deltoid and RTC to w/stand gravity | medium(1-3) to large tears (3-5) |
| approximately 6wks should be allowed before moderate stress is applied to the repair structures 12 wks before lifting against gravity | massive tears 5cm or more and re-do's |
| Crescent repairs | supra and infra free margin of cuff tendon attach directly to bone with suture anchor anchorsu-shp |
| L-shape involves | more just supra anchor placement corresponds to elbow of L l followed by repair of soft tissue components of the elbow of the L to that pt then side to side repair followed by repair of remaining lateral margin to bone with suture anchors |
| u-shape repair | supra and infra side to side repair of lateral extent of tear leading to tear margin convergence repair free lateral margin of cuff tndon directly to bone with suture anchors |
| Factors that determine RTC tears 98% chance of full thickness tear | >60 weakness in shldr abd positive impingement sign (neer's or HK) |
| Factor that are just >90 | positive painful arc 70-120 a drop arm sign weakness in ER |
| Is coplete removal of load from healing RTC tendon good for healing | no it is detrimental to healing |
| what is beneficial for healing | low level of controlled force |
| when is controlled mechanical loading most effective | applied after a initial period of immobilization |
| Stiffness comes with | full thickness tears post sup tears patients with trauma |
| thing that don't apply to stiffness | duration of symptoms gender age accompanying medical disease |
| what predicated post op pain | anticipated pain and pre-operative pain (most cases post pain lower than anticipated |
| use of early jt mobs and ROm prevents what | adhesions contractures periarticular structures |
| what prevents selective hypomobilities from developing what do they creat | PROM exercises early rehab obligate GH translation (won't slide down to tight) |
| What test would you do to determine if the obligate GH translation is caused from post tightness | Tyler's test |
| what did pt w. shldr pain after RC repair have | reduced capacity and motion of GH jt jt mobs restore these arthrokinematics |
| initial phase of tx is how long what do you during this time | 6wks protect the RTC repair until healed and preserve PROm |
| don't start PROM in first wk | lead to loss of rom |
| including caudal glide, posterior glides, and anterior glides in 30degrees scaption | accessory/arthrokinematics mvnts |
| flexion, scaption, ER (based on type of repair IR | Physiological mvnt |
| posterior capsule jt mobs increase what | internal rot |
| Best stretch for middle and lower post capsule | 0 and 30 elevation in scap plane w/ shoulder IR |
| best stretch upper and lower post capsule | 30 ext with IR |
| what perform the most PROM that won't disrupt the RTC repair | CPM and PTs |
| Supine phase I exercises are done in what stage of rehab why what wlse has low emg activity | early post op period achieve max motion while minimizing shldr mm activity aquatic therapy |
| what does aquatic therapy allow | ealier active motion in post op period with out compromising pt safety bc slow speed in water have low activation of mm |
| when is the strain on the shoulder the most what could be better | when arm is at 0 small strain and pillow and arm is at 30 degrees abd decreases strain |
| what is a safe rom motion after a repair | more than 30 of elevation in coronal /scap plane ranging from 0-60 of ER |
| RROM Guidelines | protective to the surgical repair shortened músculo-tendon unit length tension neuro-motor control submaximal pain-free |
| AROM Based on Tear Size/ conservative sling use -small tears (<1.) -medium (1-3cm) -large (3-5) -Massive(>5) | 4wks 6wk 8wks 12wks |
| Slinguse per wilk et al small medium larg massive | 7-10 days 2-3wks 2-3wks abduction pillow 1-2wks sling 2-3 wkd |
| Goals -reestablish non-pnful ROM -maintain integrity of repair -retard mm atrophy -prevent mm inhibition -decrease inflammation / pn independence in modified ADLS | Phase I: immediate post surgical phase (0-4wks) |
| Precasutions -no AROM NO lifting object, reaching behing back, excessive stretching or --sudden movements -maintain arm in brace, sling sling use for 4-5 wks no support of body weight by hands -keep incision dry and clean -no passive pulley exerci | Phase I: immediate post surgical phase (0-4wks) |
| Criteria for progression to phase II | passive forward elevation to >/=125 passive ER in scapular plane to >/=75 Passive IR in scapular plane to >/=75 passive and in scap plane=90 |
| ROM: -pendulum exercising -ABD brace/sling (sleep also) no rop or pulley finger, wirst and elbow AROM griping exercises PROM should-supine (flexion to 110 & ER/IR<30) Cervical spine AROM | Phase I: days 1-6 |
| What does PROM do | nourishment of articular cartilage assist in collagen synthesis Assits in collagen organization |
| Immobilization in how many degrees of abd | 45 |
| what increase tension in repair | shldr ADD |
| mobs are done in how many degrees of ABD | 30-45 |
| what do you educate teh pt on in phase I days 1-6 | posture jt protection importance of sling pn medication use |
| Key to the immediate phase | PROM is gentle enough to minimize mm guarding and splinting proper sling positioning with adequate wrist support no excessive pn with ROM |
| -continue sling use -pendulum exercises -PROM: supine (flex to tolerance, ER in scap >30 IR in scap to body elbow hand forearm wrist and finger AROM resisted isometric/isotonic for elbo, hand, forearm, wrist, and fingers | Phase I days 7-35 |
| begin gentle GH isometric in "balance" position what phase what is balance position | phase I 7-35 days 90-100 elevation while supine |
| WHy use balance position | the deltoid mm generates a more compressive force (horizontal) in supine it activated the cuff without superior migration of humeral head from deltoid activity that would occur in seated |
| when you can you start aquatherapy | 3wk into phase I |
| conditioning program (walking biking ) | phase I 7-35 days continue with cryotherapy |
| Goals -allowing healing of soft tissue do not overstress healing tissue normalize arthrokinematics gradually restore full PROM wk 5-6 improve neuron control of shoulder complex P | phase II protection and PROtected AROM phase : wk 5-12 |
| precautions: -no lifting -no supporting body weight on hands -no sudden jerking motions -no excessive behind back motions -no bike or ergometer until wk 6 | phase II weak 5-12 |
| criteria to progress to Phase III | full ROM minimal pain and tenderness Good MMT of IR, ER , flexion |
| Sling education | continue with brace until wk 4-5 gradually wean out of brace DC sling by end of 6th wk |
| Keys to protection and protected motion phase | do not initiate scapula or shoulder mm activation exercise until overall pn in shoulder is low exercises can not /should not create pain or increase symptoms |
| ROM -initiate AROM shoulder flexion from supine position -progressive PROM full wk 6 may use heat prior to ROM/exercises /mobs can use passive pulley normalized nomal arthrokin of shldr complex jt mobs controlled L-bar ROM self stretches ca | Phase II week 5-6 |
| AAROM to tolerated -Flex -ER/IR scap plane -Er/IR scap plane 90/90 Passive ROM -FLexion :full -ER at 90: to tolerance -IR at 90: to tolerance | PHASE II wk 7-9 |
| Key to RTC rehab in AROM | DO NOT ALLOW "shrug" sign |
| if shrug exist what do you do | continue to work on RTC exercises below 90 with no AROM > 90 |
| ROM -begin mor aggressive IR stretching mobs of post capsule/cuff critical begin ext, crossbody and sleeper stretch | phase II wk 7-9 |
| Strengthening -initiate gentle RTC submaximal isometric exercises -initiate AROM in other planes (flesion scap, add, er and IR ) pain free weight of arm RTC/scap mm small -so low load higher reps | phase II wk 7-9 |
| Initiate light isotonic program with dumbbells Side lying Shoulder musculature Scapulothoracic musculature Initiate neuromuscular control exercises Initiate trunk exercises Initiate UE endurance exercises | strengthening wk 7-9 phase IIGoal |
| Goals: -Full AROM -Maintain full PROM _dynamic shoulder activities -gradual restoration of Gh and ST strength, power, and endurance -gradual return to fan activities _-optimize neuromm control | phase III early strengthening phase wk 10-16 |
| precautions: -no lifting >5lbs exercises should be non-painful | phase III wk 10-16 |
| Criteria for progression to phase IV | |
| Initiate strengthening program Continue exercises from weeks 7-9 Scapular plane elevation Full can Rowing Prone rowing Prone horizontal abduction | Phase III wk 10 |
| phase III wk 12 | |
| phase III wk 14 | |
| Goals Maintain full non-painful AROMAdvanced conditioning exercises for enhanced functional and sports specific use Improve muscular strength, power and endurance Gradual return to all functional activities | Phase IV: Advanced Strengthening Phase: Weeks 16-22 |
| Strengthening Continue progressive strengtheningContinue dynamic stabilization Dumbbell strengthening Initiate tubing exercises side lying ER/IR tubing or side lying, Light isotonic exercise in 90/90,Advanced proprioceptive neuromuscular activities | phase IV wk 16 |
Created by:
klkoester
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