Download - Return to play after rotator cuff repair

Alessandro GianniniGruppo Medico Isokinetic, FIFA Medical Centre of Excellence, Torino

Torino, 28 Novembre 2015

Return to sport after surgery for rotator cuff

repair

RTP where we are?Let's start talking about shoulder……

…….starting from the knee

RTP where we are?

Return to the same competitive level:- 42% in non professional

player- 81% in professional

player

ACL reconstruction

Rotator Cuff Repair

Return to the same competitive level:- 66% in non professional

player- 49.9% in professional

player“Incorporating routine screening for psychological responses that could hinder returning to sport into standard postoperative rehabilitation programmes may help clinicians identify athletes at risk of not returning to sport”

“One of the hypotheses to explain this is that certain psycological factors that are not usually evaluated couldplay a role in the return to sport”

RTP where we are?Lest’s go more in depth with this systematic review…- “When studies report results in terms of pain relief or

range of motion, the results are nearly all very good, even though most patientes do no return to play at the same level”

RTP where we are?Lest’s go more in depth with this systematic review…

- “This is important information because it shows that a professional player cannot count on surgical repair of the rotator cuff to retun him or her to a sport career at the same level”

- “No difference between full tear and partial tear»

Why is RTP so difficult?“The only way to mimic the forces of

a baseball throw is to actually…… throw a ball.”

Axe M et al . Sports Health, 2009

What is the magic behind the throwing?

More than just a game…We are not the fastest animal in nature…...and surely not the strongest one….

..but we are the best throwers!

The magic of throwing• Internal rotation around

long axis of the humerus is the larget contributior to projectile velocity

• This rotation can exceed 9,000°/sec

• Is the fastest motion that human body produces• Maximum angular velocity during 100m running (in the hip) is around 800°/sec• No muscles in human body is able to generate so much rotation power• Inverse dynamic shows, the shoulder produce a large period of negative work

How can it be possible?Many things to consider….

Kinetic chain

V4

V3

V2

V1

Vg=V1+V2+V3+V4

Energy storageHow can it be possible?

• the mass moment of inertia around the long axis of humerus cause the forearm and hand lag behind the accelerating torso

Energy storage

• During the arm-cocking phase, the throwers’ humeri externally rotation exceed by 57° the active ROM

• Elastic energy can account for more than 50% of internal humeral rotation work done

• As the cocking phase begins, large torques are generated by rapid rotation of the torso

• The positioning of the shoulder and elbow at this time increase the mass moment of inertia

Implications for rehabilitation

Phase 2-3: Special considerations

Recovery of strength

Ismoetric HHD:• 0-0: ER/IR ratio

>75%• 90-0: ER/IR ratio 90-

100%• 90-90: ER/IR ratio 60-

85%

Byram et al. AJSM 2010

Most of the work is done eccentricaly.

We need to test EccIR? Cools et al. KSSTA 2015

Recovery of pain free ROM

• <20° side diff for IR

• <10° side diff for Total ROMEllenbecker BJSM 2010

We need to test «forced» passive ROM?

Phase 4: Recovery coordination

Prospective study evaluating energy flow during the tennis serve and injury

C. Martin Am J Sport Med 2014

• Noninjured player have higher energy flow from trunk and upper arm during the early and midle cocking

• Injured player have higher energy flow from trunk during late cockingPlayers with poor energy flow must create more loads at

the most distal joints

«Optimal» temporal relationship

• Many different aspects to consider with some difference between different sport

Two important features

Shoulder horizontal adduction must start before the instant the shoulder exceed 90° of

external rotation

Two important features

Avoid «delayed» peak angular velocity trunk rotationMore or less at the 85% of the

service in tennisMartin C. Med Sci Sports Exerc. 2013

Interval Sports Program

A "Interval Sports Program" is a functional rehabilitation that SIMULATES sports.These program apply progressive forces to structures on the mend and serve to gradually bring the athlete to sports as safely and quickly as possible

Phase 5: Recovery of gestures

Monday Wednesday Friday

Week three

15 short irons20 med ironsRest 10 min5 long irons15 short irons15 med ironsRest 10 min20 chips

15 short irons10 med irons 10 long ironsRest 10 min10 short irons10 med irons5 long irons5 woods

15 short irons15 med irons10 long ironsRest 10 min10 short irons10 med irons10 long irons10 woods

Week four

15 short irons10 med irons 10 long irons10 drivesRest 5 minrepeat

Play 9 holes Play 9 holes

Week five

Play 9 holes Play 9 holes Play 18 holes

Recovery of gestures

INTERVAL GOLF PROGRAMMonday Wednesday Friday

Week one

20 putts15 chipsRest 5 min15 chips

25 putts15 chipsRest 5 min25 chips

20 putts20 chipsRest 5 min20 putts20 chips 10 iron of teeRest 5 min 10 chips5 iron of tee

Week two

20 chips10 short ironsRest 5 min10 short irons15 med irons(5 iron of tee)

20 chips15 short ironsRest 10 min15 short irons15 chips putting15 med irons

15 short irons10 med ironsRest 10 min20 short irons15 chips

5 weeks3 days at week

progressive introduction of more demanding

gestures


Week one

12 FH8 BHRest 10 min13 FH7 BH



Week two




BH, backhand shots; FH, forehand shots; SR, serves


Week three30 FH25 BH10 BHRest 10 min30 FH25 BH10 SR

30 FH25 BH15 SRRest 10 min30 FH25 BH15 SR

30 FH30 BH15 SRRest 10 min30 FH15 SRRest 10 min30 FH30 BH15 SR

Week four30 FH30 BH10 SRRest 10 minPlay 3 games10 FH10 BH5 SR

30 FH30 BH10 SRRest 10 minPlay 1 set10 FH10 BH5 SR

30 FH30 BH10 SRRest 10 minPlay 1 1/2 sets10 FH10 BH3 SR

INTERVAL TENNIS PROGRAM

4 weeks, 3 days at week

Gradual increase of repetitions


“Data based” Interval Sport Program – Age-specific– Specific for the position– Specific to the level of play– Specific to the type of injury– Specific for the duration

Axe M et al . Sports Health, 2009


Return to play criteriaOur proposal

Ismoetric HHD:• 0-0: ER/IR ratio

>75%• 90-0: ER/IR ratio

90-100%• 90-90: ER/IR ratio

60-85%

• Complete recovery of strenght

At least simmetrical EccIR force• Tested by isokinetic

machine• Or HHD • Or at least simmetrical

endurance during exercises

Cools et al. KSSTA 2015

• Complete recovery of ROM

• <20° side diff for IR

• <10° side diff for Total ROM

• No pain in “forced” passive ROM

Our proposal

• No signs of dyskinesia

Return to play criteria

• No alteration in sport gestures coordination

• Use the McClure metod to evaluated

• Don’t look at simmetryClarsen et al. Br J Sports Med. 2014 Sep

McClure et al. J Athl Train. 2009

• Put attention to shoulder horizontal abduction and trunk angolar velocity

• Use video analysis (www.kinovea.org)

• Complete data-based interval training program

http://www.kinovea.org/

Thank you for attention

• Search for this presentation on www.slideshare.net

• Follow me on Twitter: @AleGiannini82

• For any questions: [email protected]

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Download - Return to play after rotator cuff repair

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