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UQ 1

RCT

QuestionAnswer
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