Considerations After Rotator Cuff RepairJuly 20, 2014 by admin
Special thanks to star physical therapist Leah Versteegen for providing this write up on a recent article from The Journal of Bone and Joint Surgery.
Shoulder rotator cuff repair aims to suture torn rotator cuff tendons and provide them with the optimal environment to heal and minimize chance of retear. Overall retear rates have decreased over the years, but are still a major concern. Better suture techniques have been thoroughly investigated but there is less attention paid to the rehabilitation protocol. Currently the gold standard for rehabilitation after surgery is to wear an abduction brace and begin physical therapy for passive range of motion within the first few weeks.
As surgical techniques have evolved from open surgery to arthroscopic surgery, there are questions as to whether this rehabilitation protocol is ideal. Animal studies have shown that longer periods of immobilization are beneficial to healing after rotator cuff repair.
A recent study published in The Journal of Bone and Joint Surgery investigated the effectiveness of immobilization after surgery in human subjects. The goal was to determine if longer periods of immobilization resulted in any clinical differences in outcomes, including shoulder range of motion, retear rates and clinical outcome scores. One hundred participants who met specific criteria and underwent arthroscopic repair of the rotator cuff were randomly sorted into two groups. One group was immobilized after surgery for 4 weeks, the other was immobilized for 8 weeks. After the allotted time of immobilization each participant underwent rehabilitation with a physical therapist that included passive range of motion then progressed to active range of motion and strengthening.
At the follow up conducted at 6 months and 24 months after surgery, there were no statistical differences between the groups with retear rates, passive range of motion or clinical scores. There were more reports of stiffness by participants who were immobilized for 8 weeks compared to those immobilized for 4 weeks. Patients were also less likely to adhere to the immobilization guidelines for a full 8 weeks compared to those immobilized for 4 weeks.
With no benefit in healing or diminished retear rate gained by immobilization for 8 weeks, it is deemed most beneficial to promote immobilization for 4 weeks after rotator cuff repair. The retear rate in this study was 10%, compared to previously reported rates of 20%-40% in studies that involved early passive range of motion before 4 weeks Thus a 4 week immobilization period may give the rotator cuff ample time to heal without increased stiffness and decrease retear rates.
Kyoung Hwan Koh, MD et al. Effect of Immobilization without Passive Exercise After Rotator Cuff Repair. In The Journal of Bone and Joint Surgery. March 2014. Vol. 96A. No. 6. PpE44 1-9.
7/16/2014 0 Comments
Special thanks to star physical therapist Leah Versteegen for providing this write up on a recent article from Sports Health.
The shoulder is one of the most mobile joints and most complex joints in the human body. It moves in no less than seven planes if you consider only movement at the glenohumeral joint. If you then take into consideration that the shoulder also involves the acromioclavicular and sternoclavicular joints as well as the scapula, the movement becomes even more complex. It is essential that the shoulder joint be controlled by well balanced muscles that control each of the aforementioned joints and the scapula, particularly in athletes that rely on shoulder strength and mobility for their sport. As the shoulder ages, well balanced movement becomes harder to achieve, presenting a challenge in injury prevention and treatment. The three most common shoulder diagnosis in the aging shoulder are rotator cuff pathology, osteoarthritis, and adhesive capsulitis.
Rotator cuff pathology is probably the best known shoulder joint injury, particularly in athletes involved in throwing sports, swimming or racquet sports, and can vary from tendinitis to a full thickness tear. Aging is associated with an increase in rotator cuff tears, both partial and full thickness. Smaller tears are often successfully treated with arthroscopic debridement, but this procedure is not as successful for full thickness tears thus leading to surgical repair of the tear. One study showed rates as high as 98 percent patient satisfaction after rotator cuff repair. The next logical question is what the most effective method of repair may be and as expected it depends on the type of tear and the patient (age, post-operative goals, health status, etc). The options are arthroscopic or open repair, single row or double row.
WIth a partial tear the tear can be completed to a full tear then repair or it can be repaired in situ, not completing the tear before repair. The former technique is most common, but in situ repairs are showing a lot of promise with research reports of 94 to 98 per cent patient satisfaction. From a biomechanical perspective, double row repairs are stronger but not necessarily leading to an advantage with clinical outcomes. Augmentation, another major mechanical emphasis in rotator cuff repair, involves using an extracellular matrix to help stimulate tendon healing. The tissue used for augmentation can be an autograft, allograft, xenograft, or synthetic material. Most recently, human dermal allograft shows the most promise with proven clinical results though new techniques for augmentation are being tested with platelet rich plasma and stem cells. Overall, it is important to differentiate age, desired level of sport, and type of sport before deciding on the treatment for rotator cuff pathology.
Osteoarthritis of the shoulder is not as common as the knee or hip, but it is not uncommon and can be quite debilitating for older athletes. Treatment options include debridement, capsular release, microfracture, glenoid resurfacing, or total shoulder arthroplasty. Again it is important to differentiate the athlete and desired goals in order to determine the best treatment. For the older recreational athlete (65 and older), total shoulder arthroplasty results in excellent long term survival rates and high level of return to sport. For younger patients (under 50) almost 50 per cent reported unsatisfactory results in on research study after total shoulder arthroplasty and survival rates were much lower than in their older counterparts. For the younger but still mature athlete, the less invasive treatments are thus more common. Though the research is inconclusive as to which option is best for this population, biological glenoid resurfacing is the most recent promising treatment added to the list of less invasive options. The resurfacing can be achieved with an Achilles tendon allograft, lateral meniscus allograft, or dermal allograft.
Adhesive capsulitis is most commonly known as frozen shoulder and is characterized by a loss of both active and passive range of motion at the glenohumeral joint. It is classified as primary idiopathic or secondary to another pathologic process, and can often be associated with diabetes or thyroid disease. Treatment with nonoperative management is highly successful and should be the first option. Conservative treatment may include a steroid injection, physical therapy, or both. Operative treatment is considered with recalcitrant adhesive capsulitis or when conservative treatment fails as can be the case more often with younger patients or those with diabetes.
When considering treatment options for shoulder pathology it is essential to consider the patients demographics, particularly age, and desired level of activity or sport participation. While older athletes may have a more progressive or advanced injury process, often they have lower performance goals.
John M. Tokish. The Mature Athlete’s Shoulder. In Sports Health. January/February 2014. Vol 6. No 1. Pp 31-35.
For most types of shoulder pain, there’s no reason to live with the pain. Expert physical therapists see and treat shoulder problems and expect results.
Learn the steps that master clinician Angela Listug-Vap of Alpine Physical Therapy takes to help people get their shoulder back on track quickly and successfully.
To schedule a thorough shoulder examination with Angela, you are invited to call our north clinic at 541-2606.
And for more information on shoulder problems, take a look at our patient guides on a variety of shoulder conditions available on our clinic website by clicking here.
Want a strong and pain-free shoulder? A reasonable place to begin is to learn about the anatomy of the shoulder.
Take a few moments to learn about the key parts of the shoulder. My document on shoulder anatomy is easy to read and has remarkably clear graphics that make learning fun and easy.
Click on the document: “A Patient’s Guide to Shoulder Anatomy.”
Knowing about the shoulder is a great starting point. If you continue to have shoulder pain or problems, you may benefit by seeing one of Alpine’s physical therapists. To schedule an appointment, call our clinics at 251-2323 or 541-2606.
For more information on shoulder conditions, view all 20 of our online shoulder Patient Guides by clicking here.
Brent Dodge is the founding owner of Alpine Physical Therapy and is a board certified orthopedic specialist. He holds additional certifications in Functional Dry Needling, Manual Physical Therapy, and Strength and Conditioning.
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