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 |