Recent Advances in Management and Rehab of …Charles Getz, MD, Martin J. Kelley, DPT, OCS, Brian G. Leggin, MS, PT, OCS APTA CSM 2006, San Diego, CA Recent Advances in the Management

Charles Getz, MD, Martin J. Kelley, DPT, OCS, Brian G. Leggin, MS, PT, OCS APTA CSM 2006, San Diego, CA Recent Advances in the Management and Rehabilitation of Massive Rotator Cuff Tears

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RECENT ADVANCES IN THE MANAGEMENT AND

REHABILITATION OF MASSIVE ROTATOR CUFF TEARS

APTA COMBINED SECTIONS MEETING

San Diego, CA February 3, 2006

Charles Getz, MD

Martin J. Kelley, DPT, OCS Brian G. Leggin, MS, PT, OCS

PENN Presbyterian Medical Center

Shoulder and Elbow Service Philadelphia, PA

40 Pages

Pathophysiology, Examination and Diagnosis

Martin J. Kelley, PT, DPT, OCS University of Pennsylvania Health System

Rotator Cuff Tendons

What is a Massive Rotator Cuff Tear

• Massive refers to size not reparability – > 5 cm (Cofield) – Two Complete Tendons (Gerber)

• Supraspinatus and infraspinatus • Supraspinatus and subscapularis • All three

– Massive �‚ irreparable – Irreparable �‚ massive


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• Attempted repair of retracted, stiff, functionally dead muscle is futile and potentially harmful

Pathogenesis-Contributing Factors

• Age related changes • Intrinsic • Extrinsic Anatomic Investigations: Aging

Intrinsic Factors

Vascular Studies

Supraspinatus Tendon Study

• Nakajima et al. JSES, 1994 – 30 cadavers – Split supraspinatus into bursal and articular sections – Histological and mechanical examination

• Results – BS tendon has strong longitudinal fibers, AS thin, disorganized – BS 2X as strong at failure – Reason for high incidence of AS tears

Rat Tendon Overuse Study-

Soslowsky et al., 2000


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Rat Model • Rats exposed to overuse protocol of treadmill running

• 10° decline, 1 hr/day, 5 days/week at 17 m/min

Results - Geometry Results - Mechanical Properties

Conclusion

• Overuse results in cuff tendon thickening BUT reduces tensile strength

Supraspinatus Tendon Strain Study

Bey et al., 2002

Create Partial Thickness Articular Side Tear

Results:Torn Specimen Strain

Results

• Intact rotator cuff – strain largely influenced by joint position – interaction of tendon and humeral head – failure strain: inferior region ~ 50% of superior region – inferior region may be susceptible to injury

• Torn rotator cuff – less tissue to support load → ↑strain – partial tears result in increased strains which could


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propagate into full tears

Extrinsic Factors

Subacromial Impingement Anatomy

Classification (Historical)

Subacromial Impingement • Stage I: edema, inflammation, 30’s, rev. • Stage II: scarring, fibrosis, 40’s, part. rev. • Stage III: tendon failure, 50’s, irrev.

Pathogenesis

Rotator Cuff Tears • Extrinsic factors- “Chicken or the Egg”

– Subacromial impingement Coracoacromial Arch Pressures

Internal Impingement • Posterior glenoid rim

Abnormal Superior Glide

• Increased superior migration with impingement and full cuff tear

• Deutch et al., JSES, 1998 • Yamaguchi et al., JSES, 2000 • Paletta, JSES, 1997 • 100% of patients with a full rotator cuff tear had abnormal

superior glide


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• After rotator cuff repair only 14 % Abnormal superior humeral head migration related to rotator cuff impingement or tear.

Yamaguchi et al.

• Humeral head superiorly migrate in some cuff tears and not in others. Superior migration does not always cause pain.

• Chronic/Degenerative- Patient with long standing full thickness retracted supraspinatus tear that may be asymptomatic or patient has adapted- “coper”

Rotator Cuff Impingement • “Impingement”

– Descriptive clinical sign – NOT a diagnosis – Mechanical irritation – Cuff tendons in the subacromial space

Tendonopathy Pathogenesis

• RE-Think – Reconsider Meaning of “IMPINGMENT”

Examination and Diagnosis

Classification of Rotator Cuff Tears Type- • Partial

– Midsubstance – Articular – Bursal

• Full • Size-


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Linear measurement – Small < 2 cm – Medium 2 – 5cm – Large > 5cm – Massive – 2 tendons

Square centimeter

Massive Tear Classification- Descriptors • Acute- Healthy tissue tears due to high energy • Acute on Chronic- “Acute extension”

– Patient with chronic asymptomatic full thickness supraspinatus tear suffers an event causing an acute tear of the infraspinatus and/or subscapularis

Diagnostic Imaging

MRI • Partial Full

History • Age > 50 • Previous episodes • Lateral-anterior shoulder pain • Recent trauma • Reports pain/weakness • Significant difficulty elevating arm • If younger – high energy trauma

Examination Findings • Usually pain with AROM • Passive and active motion probably limited (if reactive) • Resisted abduction and ER more likely to be painful and weak

(depends on time from injury) • Significant spinati atrophy • + impingement signs • + pain/weakness with resisted Abd/IR (Jobe sign)


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• + ER lag signs (supra/infra FRCT) • + Belly press/lift off (subscapularis FRCT) • + Biceps pain or long head rupture

External Rotation Lag Signs

Useful in determining the presence of : • Full thickness rotator cuff tear (supraspinatus and/or

infraspinatus) • Post-op rotator cuff rupture/deficient cuff • Significant suprascapular nerve entrapment • Other neurologic involvement influencing the

supraspinatus and infraspinatus, i.e.. C6 nerve root compression, brachial plexopathy

Lag Signs

Jobe Sign

Internal Rotation Lag Signs Useful in determining the presence of : • Subscapularis rupture (pre-post op) • Neurologic involvement causing weakness of the

subscapularis i.e., C7 nerve compression, brachial plexopathy, subscapularis denervation.

Lift-Off Test

• Gerber and Krushell (JBJS, 1991 and 1996) – Developed to diagnose tears of the subscapularis

• Greis et al. (Am J Sports Med, 1996) – Subscapularis EMG activity is approximately 70% of the MVC


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Belly-Press Test • Gerber et al. (Journal of Bone and Joint Surgery, 1996)

– Developed for individuals who could not perform the lift-off test due to decreased shoulder internal rotation passive range of motion

– Patient places hand on belly and pushes in. A positive sign is inability to keep the elbow forward (moves in to body) – To further sensitize, attempt to pull the hand from the stomach

Lift-off, IR lag sign and Belly press

Summary

• Recognize factors involved in tendon failure • Tendon strain may be major factor in cuff tear

propagation • Reconsider what “impingement” means • Use the ER lag signs and belly press test to assist in

clinical diagnosis of massive rotator cuff tear References: Bey, M., M. Ramsey, et al. (2002). "Intratendinous strain fields of the supraspinatus

tendon: Effect of a surgically created articular-surface rotator cuff tear." Journal of Shoulder and Elbow Surgery 11(6): 562-569.

Bigliani, L. U., D. Morrison, et al. (1986). "The morphology of the acromion and its relationship to rotator cuff tears." Orthop Trans 1: 228.

Bishop, J. (2004). Rotator cuff outcomes for arthroscopic versus open repairs. AAOS, New Orleans, LA.

Burkhart, S. S., S. M. Danaceau, et al. (2001). "Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair." Arthroscopy 17(9): 905-12.

Codman, E. A. (1934). Rupture of the Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa. Boston,, Thomas Todd.

Cummins, C. and G. Murrell (2003). "Mode of failure for rotator cuff repair with suture anchors identified at revision surgery." Journal of Shoulder and Elbow Surgery 12(2): 128-133.


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Deutsch, A., D. W. Altchek, et al. (1996). "Radiologic measurement of superior displacement of the humeral head in the impingement syndrome." J Shoulder Elbow Surg 5(3): 186-93.

Galatz, L. M., C. M. Ball, et al. (2004). "The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears." J Bone Joint Surg Am 86(2): 219-224.

Gaunt, B. and T. L. Uhl (2004). EMG activation of the shoulder during the elevation progression. ASSET Annual meeting, New York, NY.

Gerber, C., B. Fuchs, et al. (2000). "The Results of Repair of Massive Tears of the Rotator Cuff*{{dagger}}." J Bone Joint Surg Am 82(4): 505-.

Gerber, C., O. Hersche, et al. (1996). "Isolated rupture of the subscapularis tendon." J Bone Joint Surg 78A: 1015-1023.

Gerber, C. and R. J. Krushell (1991). "Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases." J Bone Joint Surg Br 73(3): 389-94.

Greis, P. E., J. E. Kuhn, et al. (1996). "Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation." American Journal of Sports Medicine 24(5): 589-93.

Harryman, D. T. d., L. A. Mack, et al. (1991). "Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff." J Bone Joint Surg [Am] 73(7): 982-9.

Hertel, R., F. T. Ballmer, et al. (1996). "Lag signs in the diagnosis of rotator cuff rupture." Journal of Shoulder & Elbow Surgery 5(4): 307-13.

Jobe, F. W. and D. R. Moynes (1982). "Deliniation of Diagnostic Criteria and a Rehabilitation Program for Rotator Cuff Injuries." Am J Sports Med 10(6): 336-39.

Jost, B., C. W. Pfirrmann, et al. (2000). "Clinical outcome after structural failure of rotator cuff repairs." J Bone Joint Surg Am 82(3): 304-14.

Kelley, M. (2002). Clinical Evaluation of the Shoulder. Rehabilitation of the Hand and Upper Extremity. E. Mackin, A. Callahan, T. Skirven, L. Schneider and A. Osterman. St. Louis, Mosby.

Kelley, M. and B. Leggin (1999). Shoulder Rehabilitation. Disorders of the Shoulder: Diagnosis and Management. J. P. Iannotti and G. R. Williams. Philadelphia, Lippincott, Williams, and Wilkins.

Liu, S. H. and C. L. Baker (1994). "Arthrospically assisted rotator cuff repair:correlation of functional results wiht integrity of the cuff." Arthroscopy 10: 54-60.

Lohr, J. F. and H. K. Uhthoff (1990). "The Microvascular Pattern of the Supraspinatus Tendon." Clin. Ortho. Rel. Res. 254: 35-38.

Nakajima, T., N. Rokuuma, et al. (1994). "Histologic and biomechanical characteristics of the supraspinatus tendon: reference to tearing." J Shoulder Elbow Surg 3: 79-87.

Neer, C. S., 2nd (1983). "Impingement lesions." Clin Orthop(173): 70-7. Ozaki, J., S. Fujimoto, et al. (1988). "Tears of the Rotator Cuff of the Shoulder

Associated with Pathologic Changes of the Acromion: A study in cadavers." J Bone Joint Surg 70A: 1224-1230.

Paletta, G. A., Jr., J. J. Warner, et al. (1997). "Shoulder kinematics with two-plane x-ray evaluation in patients with anterior instability or rotator cuff tearing." Journal of Shoulder & Elbow Surgery 6(6): 516-27.


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Rathbun, J. B. and I. Macnab (1970). "The Microvascular Pattern of the Rotator Cuff." J. Bone Jount Surg. 52B(3): 540-553.

Reilly, P., A. A. Amis, et al. (2003). "Mechanical factors in the initiation and propagation of tears of the rotator cuff. Quantification of strains of the supraspinatus tendon in vitro." 85(4): 594-599.

Reilly, P., A. M. J. Bull, et al. (2004). "Passive tension and gap formation of rotator cuff repairs." Journal of Shoulder and Elbow Surgery 13(6): 664-667.

Soslowsky, L. J., S. Thomopoulos, et al. (2000). "Neer Award 1999. Overuse activity injures the supraspinatus tendon in an animal model: a histologic and biomechanical study." J Shoulder Elbow Surg 9(2): 79-84.

Thomazeau, H., E. Boukobza, et al. (1997). "Prediction of rotator cuff repair results by magnetic resonance imaging." Clin Orthop(344): 275-83.

Uhthoff, H. and J. Lohr (1993). The effect of aging on the soft tissues of the shoulder. The Shoulder: A balance of Mobility and Stability. F. A. Matsen, F. A. Fu and R. Hawkins. Rosemont, IL, American Academy of Orthopaedic Surgeons: 269-278.

Walch, G., P. Boileau, et al. (1992). "Impingment of the deep surace of the supraspinatus tendon on the posterior glenoid rim:an arthroscopic study." J Shoulder Elbow Surg 1: 239-245.

Watson, E. and D. Sonnabend (2002). "Outcome of rotator cuff repair." Journal of Shoulder and Elbow Surgery 11(3): 201-211.

Wise, M. B., T. L. Uhl, et al. (2004). "The effect of limb support on muscle activation during shoulder exercises." Journal of Shoulder and Elbow Surgery 13(6): 614-620.

Yamaguchi, K., W. N. Levine, et al. (2003). "Transitioning to Arthroscopic Rotator Cuff Repair: The Pros and Cons." J Bone Joint Surg Am 85(1): 144-155.

Yamaguchi, K., M. Tetro, et al. (2001). "Natural History of asymptomatic rotator cuff tears: A longitudinal analysis of asymptomatic tears detected sonographically." J Shoulder Elbow Surg 10(3): 199-203.

Zuckerman, J. D., J. M. Leblanc, et al. (1991). "The effect of arm position and capsular

release on rotator cuff repair. A biomechanical study." J Bone Joint Surg Br 73(3): 402-5.


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NON-OPERATIVE REHABILITATION STRATEGIES FOR PATIENTS WITH MASSIVE ROTATOR CUFF TEARS

Brian G. Leggin, PT, MS, OCS PENN Presbyterian Medical Center

University of Pennsylvania Health System Philadelphia, PA

CLINICAL SIGNS


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Clinical presentation of large and massive rotator cuff tears – Pain (especially at night) – Trauma/Chronic – Atrophy – PROM > AROM – Impingement sign – Weakness of FF & ER – ER lag sign

Rotator Cuff Tears Rehabilitation Principles

• Rehabilitation of large/massive cuff tears – Restore PROM – Initiate Cuff Strengthening (manual resistance) – Need to train remaining muscles to centralize humeral head to allow

elevation – Emphasize subscapularis and deltoid


*Restore the balance point


• supine active forward elevation • gradually introduce gravity


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• add weighted ball and/or elastic resistance

SUPINE ELEVATION PROGRESSION • Begin supine with elbow flexed to 90˚ • Work up to 30 repetitions • Once patient can perform 30 reps, extend elbow

slightly • Gradually introduce gravity by raising table or prop

with pillows • Add weights, weighted ball, elastic resistance as

appropriate STUDY

• Isbell, et al, presented at ASES Closed meeting, New York, NY

• 33 subjects: – 10 normals – 10 symptomatic 2 tendon cuff tears – 13 asymptomatic cuff tears

• EMG activity of 15 muscles during 10 functional tasks

STUDY • All cuff tear patients had increased muscle activation

during all tasks vs. normals • Asymptomatic patients > subscapularis and deltoid

activity • Symptomatic patients = increased activity of torn

rotator cuff and upper trapezius STUDY

• Levy, et al, presented at ASES Closed meeting, New York, NY


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• 17 patients with massive irreparable cuff tears • All > 70 years-old • Performed supine elevation progression

STUDY • Exercise:

– Supine AROM elevation 3x/day – Gradually incline head – 6 weeks – added 2kg weight

• Results: – 90% had significant improvement at 6 weeks

CASE STUDY • 62 year-old cemetery worker • Lifting a casket and felt a “pop” in right shoulder • Immediate pain and inability to use right dominant arm

CASE STUDY • MRI revealed complete chronic cuff tear with retraction of

supraspinatus and infraspinatus • Presents with G-H crepitus, + Hawkins, supraspinatus test,

and ER lag signs at 20 & 90 • Atrophy of supra and infraspinatus fossae (bilaterally)

CASE STUDY CASE STUDY

• PENN Shoulder Score = 46 / 100 • Pain = 11 / 30 • Satisfaction = 2 / 10 • Function = 33 / 60

– No difficulty with toileting, opening a door, carrying at side


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– Some difficulty sleeping, placing light objects on shelf at and above shoulder

CASE STUDY • Treatment:

– ROM exercises (extension with stick, cross body add., internal rotation)

– Phase I strengthening (T-band ER, IR, extension) – Pulleys – Supine elevation progression – Manual resistance

OUTCOME OUTCOME

• PENN Shoulder Score = 62 / 100 • Pain = 17 / 30 • Satisfaction = 7 / 10 • Function = 38 / 60

SUMMARY • Restore PROM • Improve strength of remaining cuff muscles • Emphasize subscapularis and deltoid strengthening


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Surgical Management: Debridement, Arthroscopic, Mini-open, and

Open Repairs Charles L. Getz, MD

Assistant Professor of Orthopaedic Surgery University of Pennsylvania

Preview

When are cuff tears debrided vs. repaired? What is done(what do I need to protect)? Outcomes

“Failed Non-operative Treatment” 6 weeks of therapy minimum 3-4 months time period decide operative vs. non-operative

Repair vs. Debridement Repair Good pain relief Improved function Long Rehab(6+ mos) Results Durable Debridement Good pain relief Function unchanged Shorter rehab(3 mos) Results decline

How to tell if repairable? Shoulder Factors • Chronicity(>1 YR) • Large lag sign • (>30 degrees) • Significant atrophy on MRI


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Goutallier CORR 1994 Goutallier JSES 2003 Patient Factors • Smoker • Advanced age(>65) • Smoker • Multiple cortisone injections • Prior failed surgery Sonnabend JSES 2002

Debridement What is done? Debride cuff to glenoid rim Release biceps tendon Smooth osteophytes(G.T. and acromion)

Debridement What does a therapist have to protect? If done open: deltoid repair If done arthroscopically: nothing

Cuff Repair-Open Technique Anterior deltoid head taken down (axillary nerve at risk) +/- acromioplasty Tendon mobilized Repair through bone tunnels CA ligament repaired

Cuff Repair-Open What does the therapist have to protect? Deltoid repair Cuff repair


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How long? Probably 8-12 weeks

How long to protect cuff? Traditionally 6 weeks- Based on bone healing data Presented/unpublished data 8-12 weeks before Sharpey’s fiber restored

Cuff Repair-Mini-Open Technique Arthroscopic Acromioplasty Tendons mobilized arthroscopically Deltoid split Tendon repaired anchors or bone tunnels

Cuff Repair-Mini-Open What to protect? Cuff repair How long? 8-12 weeks

Cuff Repair-Arthroscopic Technique Arthroscopic Acromioplasty Arthroscopic cuff mobilization Margin convergence Repaired with anchors

Cuff Repair-Arthroscopic What to protect? Cuff Repair


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How long? 8-12 weeks

When cuff “retear” Entire fixation may be lost Traumatic event Suture cuts through tendon Partial healing of tendon • Tear is smaller • Fixation failed slowly enough to allow some healing

Complications Open • CA ligament incompetence • Decompensation of function (attempting to repair irrepairable

tears) • Axillary nerve injury • Deltoid dehiscence

Complications Mini-open • Deltoid pain • Stiffness • Deltoid dehiscence • Unknown healing rates

Complications Arthroscopic • High rerupture rates (96%) • Technically difficult

Results Debridement


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Multiple studies 80-90% initial good pain relief that deteriorates with time

Time to this result 3 months

Results Time frame for repair results • 6 weeks-able to sleep in bed • 6 weeks-off narcotic pain meds • 3 months- PROM close to normal • 4-5 months-patient able to lift arm • 5-6 months- functional strength • 1 year+-final result

Results Open • High patient satisfaction(85%) • Long-term follow-up (10 years) • High non-healing rates (25-50%) • Best functional results in patients with intact

repairs Open repair references

• Postacchini 2002 CORR • Harryman 1991 JBJS • Galatz JBJS 2001

Results Mini-open High patient satisfaction No anatomic data published Severud Arthroscopy 2003


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Results Arthroscopic High patient satisfaction in short term follow-up(1-2

years) 90% Is this just from the acrmoioplasty? Galatz JBJS 2004

Cuff Augmentation Biologic • Porcine Intestine • No structural support • Inflammatory reaction • Trend to worse outcomes Malcarney JSES 2005 Iannotti unpublished data Structural • Dermis • Cross-linked Porcine • No published data

Summary • Non-operative treatment is the mainstay of treatment

for massive cuff tears • Repair is first option for surgical treatment • Debridement can provide reliable pain relief, but does

not improve strength Summary

• Massive cuff repairs must be protected to allow them to heal

• Open repair has best published healing rates


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• Arthroscopic repairs have high failure rate but low complication rate

Postoperative Rotator Cuff Rehabilitation: Massive Cuff Tears

Martin J. Kelley, PT, DPT, OCS University of Pennsylvania Health System

Dangerous Territory

Philosophical Shift

• Immobilization - good- < 70’s • Immobilization – bad- > 70’s- 2000 • Immobilization – good? Now

Nirvana

Bone-tendon healing

What Determines Outcome • Tissue quality • Tear size and shape • Supraspinatus atrophy • Patient age • Patient compliance


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• Surgeon expertise • Rehabilitation • Size/weight of the arm

Biomechanics of failure

• Zuckerman et al., JSES, 1991 – Increased tension on cuff repair when arm is brought from

30 to 0 degrees • Reilly et al., JSES, 2004

– Repair tension was reduced from 34N to 0N when moving from 0 to 30 of abduction

– A 9 mm gap formed in 24 hours after repair in cadavers when loading the cuff to 34N with arm at side

• Cummins et al., JSES, 2003 – Failure occurs at suture-tendon interface

Rotator Cuff Repair

• Recognize the rotator cuff interval may need to be released- this effects rehab.

Fixation vs. Stress

• Mechanical fixation- suture/anchor holds tendon to bone

• Biologic Fixation- tendon/bone interface fuse • Avoid cuff overload

Protect Against

• TENSION!!!!!!!!!!! • TENSION!!!!!!!!!!!


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• TENSION!!!!!!!!!!!

Rehabilitation

Phase I - Goals: Weeks 1- 6 • Patient education- precautions/exercise • Permit healing- Avoid cuff loading/limit ER-30° • Control pain and inflammation- meds/therapy • Achieve good passive ROM and prevent stiffness- initiate

“passive”range of motion exercises.

Exercise Progression • A continuum of exercise that:

– Protects tissue integrity – Allows tissue healing – Prevents excessive tension loading – Prevents adhesions – Promotes return of functional strength

Core ROM and Strengthening Exercises

• Phase I ROM- Pendulum, ER, Elevation • Phase II ROM- Extension, IR, Horizontal adduction • Phase I Strengtheing- ER, IR, Extension • Phase II Strengtheing- Flexion, Abduction, supported

ER at @45 POS

Update • Some surgeons are immobilizing for the first 3- 6

weeks following cuff repairs. • Why??????? ------- Retear rate!!!!!!!!


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• Bone – tendon healing studies

Elevation ROM- Alternative • Chair stretch- When they cannot relax cuff/deltoid • Progress to supine forward elevation

Phase II 6 – 12 Weeks

Goals: • Improve ROM-

– Progress to Phase II ROM (IR, Ext., Hor. Add.) @ 8 weeks. Do not force functional IR (this is most lengthened position for cuff

• Improve neuromuscular control and strength – Use elevation progression – Progress to Phase I strengthening- meet criteria

• Start with IR and extension first – Re-educate the dynamic stabilizers with submaximal manual -avoid

cuff overload • Emphasize normal scapulohumeral rhythm

What to Expect at @ 6 Weeks • EXPECT AND RESPECT LIMITATIONS!!!

– Especially if cuff was repaired under tension – Cuff tissue does not have normal length

Large and Massive Tears

• If repaired and place in abduction pillow or if known to be repaired “under tension”, expect limitations– RESPECT limitations.

• Hersche et al., JSES, 1998 – Tears that retracted were under more tension when

advanced and re-attached • If the patient gains 20 degrees in between therapy

sessions and presents with + ER lag signs –they have torn the repair!!!


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EMG Activation During Elevation Progression.

Gaunt, B and Uhl, T, ASSET, 2004

Elevation Progression (see back of outline)

Elevation Progression (continued)

Beware of the Evil Machine

ER Progression

Phase II- Update • Progress to Phase I strengthening Criteria

– ER lag sign is negative – Minimal reactivity – No pain with submaximal resistance – Good passive elevation- > 140

• If criteria not satisfied then modify

Phase II- Update • Phase I Strengthening- Do IR and Extension first

– Move through pain free arcs and avoid repetitive “clicking and clunking”

– Limit ER to @ 20 –30 degrees – Integrate medial scapular muscles by “setting” – 2 sets 10 3sets 10 3sets 15 change color


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Phase II

Submaximal Manual Resistance- Short-arc Less Stressful Than Isometric

Warning Signs

• Increased reactivity • Excessive passive ER ROM with arm at side (occurs

abruptly between sessions) • Near normal functional IR • Limited active elevation to less than 100 degrees

beyond 8- 10 weeks • ER lag sign beyond 10 weeks (patient may continue to

present with 10-15 lag) • The weaker the patient the slower to progress

– Use very light manual resistance

Phase III 12 -16 Weeks

Goals: • Expected pain free ROM

– some stiffness of ER at the side, elevation and in functional IR is acceptable and respected

• Optimize neuromuscular control – progress strengthening from non-provocative to

provocative • Improve endurance • Initiate return to functional/work activities

Phase III


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Reality Check

• Many of the older, low demand patients require little beyond this.

• Functional strength and other compensation continues to occur

• Do not be tempted to progress to the point of

Phase III • Progress to variable resistance machines if

appropriate (after 12 weeks) – Curls – Triceps – Rows – Lat pull down in front – Work simulated activities-push/pull

• Lifting/carrying- boxes

Phase IV- 16 weeks 6 months

• Return to recreational activities – Golf- begin swinging golf club tee up on fairways – Tennis- can swing racquet forehands two hand

backhand easy serves • Work

– Patient to modified duty light lifting progress as tolerated

– Some patients may begin work conditioning – Some patients should not go back to heavy repetitive lifting

Summary

• Know the size of tear and repair mechanics


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• Respect healing- Tendon to bone • Progress the patient based on THEIR shoulder • Look out for the warning signs • There is nothing wrong with being conservative even if

you are a democrat!!!!


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Indications and Surgical Considerations for Latissimus Dorsi Transfer and Reverse

Prosthesis Charles L. Getz, MD


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Assistant professor of Orthopaedic Surgery University of Pennsylvania

Key points Rotator cuff’s roll in shoulder function Humeral head depressor(fulcrum) Centers head on socket(stability) External rotation(Strength)

Key Points Massive cuff tears can be • functional(balanced) • dysfunctional(unbalanced) Arthritis can develop(10%)

So many choices What are the patients complaints? • Pain, • Weakness, • Pain+Weakness How functional is the patient? Is the cuff repairable? Is there significant arthritis?

What is best operation? What is the complaint? What can each surgical options do? Will the patient be happy after the surgery?

Treatment options

Debridement • Pain Relief Hemiarthoplasty • Pain Relief


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• Little functional improvement Latissimus Transfer • Functional improvement • Little pain relief Reverse Prosthesis • Pain Relief and Function

Approaches to the shoulder Deltopectoral Between anterior deltoid and pec major Subscapularis frequently divided and repaired Need to protect Subscapularis repair

Approaches to the shoulder Superior Approach Anterior head of deltoid taken down and repaired Need to protect Deltoid repair

Hemiarthroplasty Pros • Pain relief consistent • Easy Technically/low complication rate Cons • AROM before=AROM after(fulcrum not restored) • Possible late glenoid based pain

Hemiarthroplasty Technique • Deltopectoral approach • Subscap usually divided and repaired Protect • Subscapularis repair


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Hemiarthroplasty Results • Difficult interpreting results—mixed patient population • Pain relief predictable • Function similar to pre-op

Latissimus Transfer Pros • Replaces posterior/Superior cuff • Improves function • Dynamic transfer? Protect • Transfer Cons • No pain relief • Technically challenging • Long Recovery

Lat Transfer Technique • Posterior approach to harvest Latissimus • Superior approach to expose Humerus • Tendon tunneled under deltoid • Lat sewn into the greater tubersoity

Lat Transfer Results • High patient satisfaction (80%) • Improves Active ROM(Ave 50 FF, 13 ER) • Improves function for low weight • Does not improve ability to hold 15 pound weight at

shoulder height Reverse prosthesis

Pros • Fulcrum restored


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• Pain relief • Shoulder level function Protect • Implant • Too much motion can cause dislocation Cons • Little ER strength • Technically difficult • Higher complication rate • Longevity of implant

Reverse Prosthesis Technique • Deltopectoral approach or superior approach • No cuff repair made • Stability from deltoid tension/geometry of implant • Function-remaining cuff/deltoid tension

Reverse Prosthesis Results • 92-98% satisfaction short term • Pain relief near 100% • Improved Outcomes scores • High complication rates(33-50%) Dislocation Component loosening Infection

Summary

• Multiple surgical options available for the treatment of irreparable rotator cuff tears

Treatment is based on patient age, function, and expectation


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REHABILITATION FOLLOWING TENDON TRANSFERS for MASSIVE ROTATOR

CUFF TEARS Brian G. Leggin, MS, PT, OCS

Latissimus Dorsi Transfer Rehabilitation • Same as for large / massive cuff repairs • Except……… Latissimus Dorsi Transfer Rehabilitation

• Latissimus still fires when the arm is adducted and extended!! • Must re-train the latissimus to act as an external rotator • Emphasize internal rotation and deltoid strength Latissimus Dorsi Transfer Rehabilitation

• Neuro-muscular re-education!! • Stimulate latissimus with Adduction

STUDY • PURPOSE:

– To evaluate range of motion, strength, pain, satisfaction, and function of patients who have had latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.


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METHODS • Retrospective study of 14 patients who had lat transfer

surgery • All patients completed Penn Shoulder Score at initial office

visit and most recent follow-up visit • Pre and post-operative passive and active range of motion of

both shoulders METHODS

• Strength of ER, IR, and elevation in POS at 45° • ER force while operative arm performed adduction

RESULTS • 14 of 20 possible patients seen for follow-up • Nine males, Five females • Mean age = 54.8 (SD ± 7.4, range = 44 – 68) • All gave informed consent

RESULTS ALL PATIENTS AROM

Pre Post p FE 106° 118° .56 ER @ 0 17° 26° .30 ER @ 90 24° 50° .05*

RESULTS POOR vs GOOD AROM


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RESULTS ALL PATIENTS STRENGTH (kg)

Inv Uninv % ER 2.8 7.7 34% IR 14.0 14.6 98% Elevation 7.7 12.7 63%

STRENGTH RESULTS POOR vs GOOD

Poor Good ER 1.38kg 3.6kg IR 6.84kg 14.03kg Elevation 3.5kg 7.73kg

ER FORCE with ADDUCTION PENN SHOULDER SCORE GOOD vs POOR RESULTS

FUNCTION • 5 poor result patients could not:

– Place hand behind head – gallon container on shelf at shoulder level – reach a shelf overhead – soup can a shelf overhead – gallon container on a shelf overhead – 4/5 could not place soup can a shelf at shoulder level


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SUMMARY

• Latissimus dorsi transfer can be a successful procedure • External rotation force increases when arm forcefully adducts • Good subscap and deltoid function appears necessary for

better outcome FUTURE RESEARCH

• Doesn’t work – why? • Works – why? • Further analyze EMG data • Randomized prospective study

REVERSE PROSTHESIS REHABILITATION

• Early motion depends on surgeon preference and quality of glenoid fixation

• Some advocate no movement until 6 weeks post-op • Some initiate no postoperative rehabilitation • Others begin PROM first post-op day with limits of 90° FE and

0° ER • Literature lacking in description of rehabilitation

Rittmeister and Kerschbaumer, JSES 2001

• Reported on 7 patients (8 shoulders) with RA and irreparable rotator cuff

• PROM on 1st post-op day • Active flexion and abduction beyond 90° allowed after 6 weeks

unless delayed union of acromion osteotomy Rittmeister and Kerschbaumer

• Constant score improved from mean 17/100 to 63/100


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• Postop active painfree shoulder range allowed use of hand at umbilicus in 2 patients, the head in 2, and above the head in 2 (one patient deceased & 1 implant removed)

Frankle, et al JBJS 2005 • 64 patients (66 shoulders) with cuff deficiency and arthritis (2-

year follow-up) • Rehab: Shoulder immobilizer for 4 weeks and PROM begun

day 1 (limits of 90° FE and 0° ER • 4-6 weeks: sling and AAROM • 8-10 weeks: AROM • Resistive exercise begun when subscap healed (usually 12

weeks)

Frankle, et al JBJS 2005 Pre-op Post-op • ASES score: 34.3 68.2 • Pain: 6.3 2.2 • ROM: FE 55° 105° • ABD: 41.4° 101.8° • ER: 12° 41.1°

CURRENT PENN APPROACH • Patients with a good deltoid allowed to use arm for waist level

activities first 6 weeks. Then use arm unrestricted. • Patients with post-op stiffness begun with PROM 7-10 days

post-op with restrictions • Patients with poor deltoid begun on strengthening and

functional training at 6 weeks SUMMARY

• Rehabilitation following reverse prosthesis is not standardized


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• Preoperative deltoid function may play a role in postoperative

shoulder function • Rehab may vary depending on patients goals and abilities

LATISSIMUS DORSI TRANSFER REFERENCES:

1. Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of

the rotator cuff. Clin Orthop. 1992;275:152-160. 2. Gerber C, Vinh TS, Hertel R, Hess C. Latissimus dorsi transfer for the

treatment of massive tears of the rotator cuff. Clin. Orthop. 1988;232:51-61.

3. Warner JP, Parsons IM. Latissimus dorsi tendon transfer: A comparative

analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. Journal of Shoulder & Elbow Surgery. 2001;10:514-521.

REVERSE PROSTHESIS REFERENCES:

1. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M: The

reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients. JBJS 87-A: 1697-1705; 2005.

2. Rittmeister M, Kerschbaumer F: Grammont reverse total shoulder

arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg 10: 17-22; 2001.

3. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D: Grammont

inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicenter study of 80 shoulders. JBJS (BR) 86-B:388-395; 2004.

Documents

Recent Advances in Management and Rehab of …Charles Getz, MD, Martin J. Kelley, DPT, OCS, Brian G. Leggin, MS, PT, OCS APTA CSM 2006, San Diego, CA Recent Advances in the Management