1
Rotator Cuff Dysfunction Surgical Intervention and
Postoperative Rehab
B r i a n S c h i f f P T O C S C S C S
Provider Disclaimer
bull Allied Health Education and the presenter of this webinar do not have any financial or other
associations with the manufacturers of any products or suppliers of commercial services that may be
discussed or displayed in this presentation bull There was no commercial support for this
presentationbull The views expressed in this presentation are the views
and opinions of the presenterbull Participants must use discretion when using the
information contained in this presentation
Background
bull Supervisor - Raleigh Orthopaedic Performance Center
bull Practiced since 1996 in outpatient sportsortho clinics
bull S amp C coach for MLS - Columbus Crew 2002-2006
bull Owned my own training facility 2000-2010
bull FMS certified board certified orthopaedic clinical specialist (OCS) credentialed in dry needling
bull Write for PFP Magazine
bull PT consultant for Carolina Hurricanes
2
wwwapcraleighcom
Objectives
bull Understand basic surgical
intervention and considerations
bull Review outcome data for RC repair
bull Recognize post-op precautions and
contraindications
bull Apply sound evidenced-based rehab
strategies to ensure optimal outcomes
Rotator Cuff Tears
bull Not always traumatic
bull Traumatic tend to be larger amp should be fixed sooner
bull Partial tears gt 50 of tendon behave more like full thickness tear
bull Arthroscopic repair is the standard of care in 2015
3
Rotator Cuff Tears
bull Partial vs full thickness
bull Articular vs bursal sided
bull Pain level varies
bull Size of tear does not always predict
amount of dysfunction
Classification
bull Small = lt 1 cm
bull Medium = 1 - 3 cm
bull Large = 3-5 cm
bull Massive = gt 5 cm
RC Tear
HH
IS
SS
4
Symptoms of RCT
bull Painful arc of motion
bull Crepitus
bull Weakness
bull Positive impingement signs
bull Difficulty with overhead activities or
overhead sports
bull Nocturnal pain
Partial Thickness Tears
bull Articular surface partial tear
bull Bursal surface partial tear
bull Grade 1 (lt3 mm deep)
bull Grade 2 (3-6 mm deep or approximately
50 of the thickness of tendon)
bull Grade 3 (gt 6 mm deep or more than
50 of the thickness of the tendon)
Risk factors - PTRCTs
Intrinsic
bull Age (risk
increases over time)
bull Decreased
vascularity
Extrinsic
bull Subacromialimpingement
bull GH instability
bull Internal impingement
Matthewson et al Adv Orthop 2015
5
Subacromial Impingement
In many cases there is an anatomical reason for persistent pain
Internal Impingement
bull Cocking phase
Pathomechanics
bull humeral ER
bull horizontal extension
bull anterior translation
Pinches undersurface RC amp labrum between GT and glenoid
Prevalence of PTRCT
bull MRI of asymptomatic shoulders
bull Overall prevalence of PTRCTs was
20
bull In patients under the age of 40 the
prevalence was approximately 4
bull In patients over the age of 60 the
prevalence was 26
Sher et al JBJS 1995
6
Overhead Athletes
bull In 2003 Connor et al
performed MRIs in the shoulders of asymptomatic
elite overhead athletes
bull In 20 athletes the overall
prevalence of rotator cuff tears (ie partial or full
thickness) was 40 in the
dominant throwing shoulder
bull Importantly at a 5-year
follow-up none of the athletes developed shoulder
symptoms requiring treatment and none of them
had appreciable decreases in
their level of play
Throwing athletes
In the throwing athlete due to the time off
stiffness and decreased range of motion
associated with surgery conservative management is the treatment of choice for
tears involving up to 75 of the tendon
thickness
Rudzki amp Shaffer Clin Sports Med 2008
Imaging
bull While MRI has limits in its ability to
accurately detect PTRCTs MR
arthrography remains the imaging modality of choice
bull Its high mean sensitivity (859) and specificity (960) place it superior to
other imaging modalities
de Jesus et al Am J Roent 2009
7
MRI - Rotator Cuff Tear
Image Source - Centeno-Schultz Clinic
bull Despite advances in imaging technologies arthroscopy remains the gold standard for diagnosing PTRCTs
bull Arthroscopy allows direct visualization of the bursal and articular surfaces of the rotator cuff as well as the anatomic footprint
bull Arthroscopy provides the ability to probe the soft tissues to identify areas of tearing that would otherwise be undetectable
Finnan amp Crosby JSES 2010
PRP - No Surgery
bull In 2013 Kesikburun et al evaluated the effect of PRP in patients with chronic rotator cuff tendinopathy (ie tendinosis or partial thickness rotator cuff tears excluding full thickness rotator cuff tears)
bull In this study 40 patients were randomized to receive a PRP injection versus saline placebo control
bull At a one-year follow-up there was no significant difference in pain disability or shoulder range of motion between PRP and saline controls
AJSM 2013
8
PRP During Surgery
bull At 3 months of follow-up there were initially significantly
better pain scores and improved forward elevation in patients treated with PRP However by 6 months there was
no significant difference between PRP treated patients and control patients
bull Prospective randomized trial of 80 patients undergoing
rotator cuff repair by Castricini et al there was no significant difference in Constant score between patients
treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up
Randelli et a JSES 2011
Castricini et al AJSM 2011
PRP Conclusions
More Questions Than Answers
Debride vs Repair
bull Percentage of tendon torn
bull Age
bull Tear configuration
bull Concomitant pathologies (ie labral
tear and impingement)
bull Work or sport-related factors
bull Disease processprojection
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
2
wwwapcraleighcom
Objectives
bull Understand basic surgical
intervention and considerations
bull Review outcome data for RC repair
bull Recognize post-op precautions and
contraindications
bull Apply sound evidenced-based rehab
strategies to ensure optimal outcomes
Rotator Cuff Tears
bull Not always traumatic
bull Traumatic tend to be larger amp should be fixed sooner
bull Partial tears gt 50 of tendon behave more like full thickness tear
bull Arthroscopic repair is the standard of care in 2015
3
Rotator Cuff Tears
bull Partial vs full thickness
bull Articular vs bursal sided
bull Pain level varies
bull Size of tear does not always predict
amount of dysfunction
Classification
bull Small = lt 1 cm
bull Medium = 1 - 3 cm
bull Large = 3-5 cm
bull Massive = gt 5 cm
RC Tear
HH
IS
SS
4
Symptoms of RCT
bull Painful arc of motion
bull Crepitus
bull Weakness
bull Positive impingement signs
bull Difficulty with overhead activities or
overhead sports
bull Nocturnal pain
Partial Thickness Tears
bull Articular surface partial tear
bull Bursal surface partial tear
bull Grade 1 (lt3 mm deep)
bull Grade 2 (3-6 mm deep or approximately
50 of the thickness of tendon)
bull Grade 3 (gt 6 mm deep or more than
50 of the thickness of the tendon)
Risk factors - PTRCTs
Intrinsic
bull Age (risk
increases over time)
bull Decreased
vascularity
Extrinsic
bull Subacromialimpingement
bull GH instability
bull Internal impingement
Matthewson et al Adv Orthop 2015
5
Subacromial Impingement
In many cases there is an anatomical reason for persistent pain
Internal Impingement
bull Cocking phase
Pathomechanics
bull humeral ER
bull horizontal extension
bull anterior translation
Pinches undersurface RC amp labrum between GT and glenoid
Prevalence of PTRCT
bull MRI of asymptomatic shoulders
bull Overall prevalence of PTRCTs was
20
bull In patients under the age of 40 the
prevalence was approximately 4
bull In patients over the age of 60 the
prevalence was 26
Sher et al JBJS 1995
6
Overhead Athletes
bull In 2003 Connor et al
performed MRIs in the shoulders of asymptomatic
elite overhead athletes
bull In 20 athletes the overall
prevalence of rotator cuff tears (ie partial or full
thickness) was 40 in the
dominant throwing shoulder
bull Importantly at a 5-year
follow-up none of the athletes developed shoulder
symptoms requiring treatment and none of them
had appreciable decreases in
their level of play
Throwing athletes
In the throwing athlete due to the time off
stiffness and decreased range of motion
associated with surgery conservative management is the treatment of choice for
tears involving up to 75 of the tendon
thickness
Rudzki amp Shaffer Clin Sports Med 2008
Imaging
bull While MRI has limits in its ability to
accurately detect PTRCTs MR
arthrography remains the imaging modality of choice
bull Its high mean sensitivity (859) and specificity (960) place it superior to
other imaging modalities
de Jesus et al Am J Roent 2009
7
MRI - Rotator Cuff Tear
Image Source - Centeno-Schultz Clinic
bull Despite advances in imaging technologies arthroscopy remains the gold standard for diagnosing PTRCTs
bull Arthroscopy allows direct visualization of the bursal and articular surfaces of the rotator cuff as well as the anatomic footprint
bull Arthroscopy provides the ability to probe the soft tissues to identify areas of tearing that would otherwise be undetectable
Finnan amp Crosby JSES 2010
PRP - No Surgery
bull In 2013 Kesikburun et al evaluated the effect of PRP in patients with chronic rotator cuff tendinopathy (ie tendinosis or partial thickness rotator cuff tears excluding full thickness rotator cuff tears)
bull In this study 40 patients were randomized to receive a PRP injection versus saline placebo control
bull At a one-year follow-up there was no significant difference in pain disability or shoulder range of motion between PRP and saline controls
AJSM 2013
8
PRP During Surgery
bull At 3 months of follow-up there were initially significantly
better pain scores and improved forward elevation in patients treated with PRP However by 6 months there was
no significant difference between PRP treated patients and control patients
bull Prospective randomized trial of 80 patients undergoing
rotator cuff repair by Castricini et al there was no significant difference in Constant score between patients
treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up
Randelli et a JSES 2011
Castricini et al AJSM 2011
PRP Conclusions
More Questions Than Answers
Debride vs Repair
bull Percentage of tendon torn
bull Age
bull Tear configuration
bull Concomitant pathologies (ie labral
tear and impingement)
bull Work or sport-related factors
bull Disease processprojection
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
3
Rotator Cuff Tears
bull Partial vs full thickness
bull Articular vs bursal sided
bull Pain level varies
bull Size of tear does not always predict
amount of dysfunction
Classification
bull Small = lt 1 cm
bull Medium = 1 - 3 cm
bull Large = 3-5 cm
bull Massive = gt 5 cm
RC Tear
HH
IS
SS
4
Symptoms of RCT
bull Painful arc of motion
bull Crepitus
bull Weakness
bull Positive impingement signs
bull Difficulty with overhead activities or
overhead sports
bull Nocturnal pain
Partial Thickness Tears
bull Articular surface partial tear
bull Bursal surface partial tear
bull Grade 1 (lt3 mm deep)
bull Grade 2 (3-6 mm deep or approximately
50 of the thickness of tendon)
bull Grade 3 (gt 6 mm deep or more than
50 of the thickness of the tendon)
Risk factors - PTRCTs
Intrinsic
bull Age (risk
increases over time)
bull Decreased
vascularity
Extrinsic
bull Subacromialimpingement
bull GH instability
bull Internal impingement
Matthewson et al Adv Orthop 2015
5
Subacromial Impingement
In many cases there is an anatomical reason for persistent pain
Internal Impingement
bull Cocking phase
Pathomechanics
bull humeral ER
bull horizontal extension
bull anterior translation
Pinches undersurface RC amp labrum between GT and glenoid
Prevalence of PTRCT
bull MRI of asymptomatic shoulders
bull Overall prevalence of PTRCTs was
20
bull In patients under the age of 40 the
prevalence was approximately 4
bull In patients over the age of 60 the
prevalence was 26
Sher et al JBJS 1995
6
Overhead Athletes
bull In 2003 Connor et al
performed MRIs in the shoulders of asymptomatic
elite overhead athletes
bull In 20 athletes the overall
prevalence of rotator cuff tears (ie partial or full
thickness) was 40 in the
dominant throwing shoulder
bull Importantly at a 5-year
follow-up none of the athletes developed shoulder
symptoms requiring treatment and none of them
had appreciable decreases in
their level of play
Throwing athletes
In the throwing athlete due to the time off
stiffness and decreased range of motion
associated with surgery conservative management is the treatment of choice for
tears involving up to 75 of the tendon
thickness
Rudzki amp Shaffer Clin Sports Med 2008
Imaging
bull While MRI has limits in its ability to
accurately detect PTRCTs MR
arthrography remains the imaging modality of choice
bull Its high mean sensitivity (859) and specificity (960) place it superior to
other imaging modalities
de Jesus et al Am J Roent 2009
7
MRI - Rotator Cuff Tear
Image Source - Centeno-Schultz Clinic
bull Despite advances in imaging technologies arthroscopy remains the gold standard for diagnosing PTRCTs
bull Arthroscopy allows direct visualization of the bursal and articular surfaces of the rotator cuff as well as the anatomic footprint
bull Arthroscopy provides the ability to probe the soft tissues to identify areas of tearing that would otherwise be undetectable
Finnan amp Crosby JSES 2010
PRP - No Surgery
bull In 2013 Kesikburun et al evaluated the effect of PRP in patients with chronic rotator cuff tendinopathy (ie tendinosis or partial thickness rotator cuff tears excluding full thickness rotator cuff tears)
bull In this study 40 patients were randomized to receive a PRP injection versus saline placebo control
bull At a one-year follow-up there was no significant difference in pain disability or shoulder range of motion between PRP and saline controls
AJSM 2013
8
PRP During Surgery
bull At 3 months of follow-up there were initially significantly
better pain scores and improved forward elevation in patients treated with PRP However by 6 months there was
no significant difference between PRP treated patients and control patients
bull Prospective randomized trial of 80 patients undergoing
rotator cuff repair by Castricini et al there was no significant difference in Constant score between patients
treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up
Randelli et a JSES 2011
Castricini et al AJSM 2011
PRP Conclusions
More Questions Than Answers
Debride vs Repair
bull Percentage of tendon torn
bull Age
bull Tear configuration
bull Concomitant pathologies (ie labral
tear and impingement)
bull Work or sport-related factors
bull Disease processprojection
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
4
Symptoms of RCT
bull Painful arc of motion
bull Crepitus
bull Weakness
bull Positive impingement signs
bull Difficulty with overhead activities or
overhead sports
bull Nocturnal pain
Partial Thickness Tears
bull Articular surface partial tear
bull Bursal surface partial tear
bull Grade 1 (lt3 mm deep)
bull Grade 2 (3-6 mm deep or approximately
50 of the thickness of tendon)
bull Grade 3 (gt 6 mm deep or more than
50 of the thickness of the tendon)
Risk factors - PTRCTs
Intrinsic
bull Age (risk
increases over time)
bull Decreased
vascularity
Extrinsic
bull Subacromialimpingement
bull GH instability
bull Internal impingement
Matthewson et al Adv Orthop 2015
5
Subacromial Impingement
In many cases there is an anatomical reason for persistent pain
Internal Impingement
bull Cocking phase
Pathomechanics
bull humeral ER
bull horizontal extension
bull anterior translation
Pinches undersurface RC amp labrum between GT and glenoid
Prevalence of PTRCT
bull MRI of asymptomatic shoulders
bull Overall prevalence of PTRCTs was
20
bull In patients under the age of 40 the
prevalence was approximately 4
bull In patients over the age of 60 the
prevalence was 26
Sher et al JBJS 1995
6
Overhead Athletes
bull In 2003 Connor et al
performed MRIs in the shoulders of asymptomatic
elite overhead athletes
bull In 20 athletes the overall
prevalence of rotator cuff tears (ie partial or full
thickness) was 40 in the
dominant throwing shoulder
bull Importantly at a 5-year
follow-up none of the athletes developed shoulder
symptoms requiring treatment and none of them
had appreciable decreases in
their level of play
Throwing athletes
In the throwing athlete due to the time off
stiffness and decreased range of motion
associated with surgery conservative management is the treatment of choice for
tears involving up to 75 of the tendon
thickness
Rudzki amp Shaffer Clin Sports Med 2008
Imaging
bull While MRI has limits in its ability to
accurately detect PTRCTs MR
arthrography remains the imaging modality of choice
bull Its high mean sensitivity (859) and specificity (960) place it superior to
other imaging modalities
de Jesus et al Am J Roent 2009
7
MRI - Rotator Cuff Tear
Image Source - Centeno-Schultz Clinic
bull Despite advances in imaging technologies arthroscopy remains the gold standard for diagnosing PTRCTs
bull Arthroscopy allows direct visualization of the bursal and articular surfaces of the rotator cuff as well as the anatomic footprint
bull Arthroscopy provides the ability to probe the soft tissues to identify areas of tearing that would otherwise be undetectable
Finnan amp Crosby JSES 2010
PRP - No Surgery
bull In 2013 Kesikburun et al evaluated the effect of PRP in patients with chronic rotator cuff tendinopathy (ie tendinosis or partial thickness rotator cuff tears excluding full thickness rotator cuff tears)
bull In this study 40 patients were randomized to receive a PRP injection versus saline placebo control
bull At a one-year follow-up there was no significant difference in pain disability or shoulder range of motion between PRP and saline controls
AJSM 2013
8
PRP During Surgery
bull At 3 months of follow-up there were initially significantly
better pain scores and improved forward elevation in patients treated with PRP However by 6 months there was
no significant difference between PRP treated patients and control patients
bull Prospective randomized trial of 80 patients undergoing
rotator cuff repair by Castricini et al there was no significant difference in Constant score between patients
treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up
Randelli et a JSES 2011
Castricini et al AJSM 2011
PRP Conclusions
More Questions Than Answers
Debride vs Repair
bull Percentage of tendon torn
bull Age
bull Tear configuration
bull Concomitant pathologies (ie labral
tear and impingement)
bull Work or sport-related factors
bull Disease processprojection
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
5
Subacromial Impingement
In many cases there is an anatomical reason for persistent pain
Internal Impingement
bull Cocking phase
Pathomechanics
bull humeral ER
bull horizontal extension
bull anterior translation
Pinches undersurface RC amp labrum between GT and glenoid
Prevalence of PTRCT
bull MRI of asymptomatic shoulders
bull Overall prevalence of PTRCTs was
20
bull In patients under the age of 40 the
prevalence was approximately 4
bull In patients over the age of 60 the
prevalence was 26
Sher et al JBJS 1995
6
Overhead Athletes
bull In 2003 Connor et al
performed MRIs in the shoulders of asymptomatic
elite overhead athletes
bull In 20 athletes the overall
prevalence of rotator cuff tears (ie partial or full
thickness) was 40 in the
dominant throwing shoulder
bull Importantly at a 5-year
follow-up none of the athletes developed shoulder
symptoms requiring treatment and none of them
had appreciable decreases in
their level of play
Throwing athletes
In the throwing athlete due to the time off
stiffness and decreased range of motion
associated with surgery conservative management is the treatment of choice for
tears involving up to 75 of the tendon
thickness
Rudzki amp Shaffer Clin Sports Med 2008
Imaging
bull While MRI has limits in its ability to
accurately detect PTRCTs MR
arthrography remains the imaging modality of choice
bull Its high mean sensitivity (859) and specificity (960) place it superior to
other imaging modalities
de Jesus et al Am J Roent 2009
7
MRI - Rotator Cuff Tear
Image Source - Centeno-Schultz Clinic
bull Despite advances in imaging technologies arthroscopy remains the gold standard for diagnosing PTRCTs
bull Arthroscopy allows direct visualization of the bursal and articular surfaces of the rotator cuff as well as the anatomic footprint
bull Arthroscopy provides the ability to probe the soft tissues to identify areas of tearing that would otherwise be undetectable
Finnan amp Crosby JSES 2010
PRP - No Surgery
bull In 2013 Kesikburun et al evaluated the effect of PRP in patients with chronic rotator cuff tendinopathy (ie tendinosis or partial thickness rotator cuff tears excluding full thickness rotator cuff tears)
bull In this study 40 patients were randomized to receive a PRP injection versus saline placebo control
bull At a one-year follow-up there was no significant difference in pain disability or shoulder range of motion between PRP and saline controls
AJSM 2013
8
PRP During Surgery
bull At 3 months of follow-up there were initially significantly
better pain scores and improved forward elevation in patients treated with PRP However by 6 months there was
no significant difference between PRP treated patients and control patients
bull Prospective randomized trial of 80 patients undergoing
rotator cuff repair by Castricini et al there was no significant difference in Constant score between patients
treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up
Randelli et a JSES 2011
Castricini et al AJSM 2011
PRP Conclusions
More Questions Than Answers
Debride vs Repair
bull Percentage of tendon torn
bull Age
bull Tear configuration
bull Concomitant pathologies (ie labral
tear and impingement)
bull Work or sport-related factors
bull Disease processprojection
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
6
Overhead Athletes
bull In 2003 Connor et al
performed MRIs in the shoulders of asymptomatic
elite overhead athletes
bull In 20 athletes the overall
prevalence of rotator cuff tears (ie partial or full
thickness) was 40 in the
dominant throwing shoulder
bull Importantly at a 5-year
follow-up none of the athletes developed shoulder
symptoms requiring treatment and none of them
had appreciable decreases in
their level of play
Throwing athletes
In the throwing athlete due to the time off
stiffness and decreased range of motion
associated with surgery conservative management is the treatment of choice for
tears involving up to 75 of the tendon
thickness
Rudzki amp Shaffer Clin Sports Med 2008
Imaging
bull While MRI has limits in its ability to
accurately detect PTRCTs MR
arthrography remains the imaging modality of choice
bull Its high mean sensitivity (859) and specificity (960) place it superior to
other imaging modalities
de Jesus et al Am J Roent 2009
7
MRI - Rotator Cuff Tear
Image Source - Centeno-Schultz Clinic
bull Despite advances in imaging technologies arthroscopy remains the gold standard for diagnosing PTRCTs
bull Arthroscopy allows direct visualization of the bursal and articular surfaces of the rotator cuff as well as the anatomic footprint
bull Arthroscopy provides the ability to probe the soft tissues to identify areas of tearing that would otherwise be undetectable
Finnan amp Crosby JSES 2010
PRP - No Surgery
bull In 2013 Kesikburun et al evaluated the effect of PRP in patients with chronic rotator cuff tendinopathy (ie tendinosis or partial thickness rotator cuff tears excluding full thickness rotator cuff tears)
bull In this study 40 patients were randomized to receive a PRP injection versus saline placebo control
bull At a one-year follow-up there was no significant difference in pain disability or shoulder range of motion between PRP and saline controls
AJSM 2013
8
PRP During Surgery
bull At 3 months of follow-up there were initially significantly
better pain scores and improved forward elevation in patients treated with PRP However by 6 months there was
no significant difference between PRP treated patients and control patients
bull Prospective randomized trial of 80 patients undergoing
rotator cuff repair by Castricini et al there was no significant difference in Constant score between patients
treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up
Randelli et a JSES 2011
Castricini et al AJSM 2011
PRP Conclusions
More Questions Than Answers
Debride vs Repair
bull Percentage of tendon torn
bull Age
bull Tear configuration
bull Concomitant pathologies (ie labral
tear and impingement)
bull Work or sport-related factors
bull Disease processprojection
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
7
MRI - Rotator Cuff Tear
Image Source - Centeno-Schultz Clinic
bull Despite advances in imaging technologies arthroscopy remains the gold standard for diagnosing PTRCTs
bull Arthroscopy allows direct visualization of the bursal and articular surfaces of the rotator cuff as well as the anatomic footprint
bull Arthroscopy provides the ability to probe the soft tissues to identify areas of tearing that would otherwise be undetectable
Finnan amp Crosby JSES 2010
PRP - No Surgery
bull In 2013 Kesikburun et al evaluated the effect of PRP in patients with chronic rotator cuff tendinopathy (ie tendinosis or partial thickness rotator cuff tears excluding full thickness rotator cuff tears)
bull In this study 40 patients were randomized to receive a PRP injection versus saline placebo control
bull At a one-year follow-up there was no significant difference in pain disability or shoulder range of motion between PRP and saline controls
AJSM 2013
8
PRP During Surgery
bull At 3 months of follow-up there were initially significantly
better pain scores and improved forward elevation in patients treated with PRP However by 6 months there was
no significant difference between PRP treated patients and control patients
bull Prospective randomized trial of 80 patients undergoing
rotator cuff repair by Castricini et al there was no significant difference in Constant score between patients
treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up
Randelli et a JSES 2011
Castricini et al AJSM 2011
PRP Conclusions
More Questions Than Answers
Debride vs Repair
bull Percentage of tendon torn
bull Age
bull Tear configuration
bull Concomitant pathologies (ie labral
tear and impingement)
bull Work or sport-related factors
bull Disease processprojection
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
8
PRP During Surgery
bull At 3 months of follow-up there were initially significantly
better pain scores and improved forward elevation in patients treated with PRP However by 6 months there was
no significant difference between PRP treated patients and control patients
bull Prospective randomized trial of 80 patients undergoing
rotator cuff repair by Castricini et al there was no significant difference in Constant score between patients
treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up
Randelli et a JSES 2011
Castricini et al AJSM 2011
PRP Conclusions
More Questions Than Answers
Debride vs Repair
bull Percentage of tendon torn
bull Age
bull Tear configuration
bull Concomitant pathologies (ie labral
tear and impingement)
bull Work or sport-related factors
bull Disease processprojection
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
9
Arthroscopic Repair
bull Advantages = no detachment of deltoid
less pain and likely shorter OR time
bull Disadvantages = larger learning curve
on part of the surgeon
Arthroscopy
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
10
Open Repair
bull Take down anterior deltoid
bull Open acromioplasty
bull Advantages = great exposure
bull Potential complications = deltoid
dehiscence and slower rehab allowing for healing of deltoid
Open repair
Mini-Open RC Repair
bull Arthroscopic acromioplasty
bull Split middle deltoid
bull Open rotator cuff repair
Advantages
bull Avoid take down of deltoid
bull Less post-op pain
Complications
bull Deltoid retraction
bull Limited exposure
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
11
Surgical videos
Double-Row vs Single-row
bull Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine
which meta-analysis provides the current best available evidence
bull Six meta-analyses found no differences between SR and DR RCR for patient outcomes whereas 2 favored DR RCR for tears greater than 3 cm Two meta-analyses found no
structural healing differences between SR and DR RCR whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears
bull Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR
Mascarenhas et al Arthroscopy 2014
Outcomes re-tear rates
bull Re-tear rates after arthroscopic single-row double-Row and suture bridge rotator cuff repair at a
minimum of 1 year of imaging follow-up
bull Thirty-two studies met the inclusion criteria yielding a total of 2048 repairs
bull Both DR and SB have lower re-tear rates than SR in
most tear size categories
bull No differences in re-tear rates were found between DR and SB
Hein et al Arthroscopy 2015
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
12
Outcomes re-tear rates
bull Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row wdouble-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates
bull Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs especially with regard to partial-thickness re-tears
bull No detectable differences in improvement in outcomes
scores between single-row and double-row repairs
Millett et al JSES 2014
Return to Sport After Rotator Cuff Tear Repair
bull Twenty-five studies were reviewed including 859 patients (683
athletes) all treated surgically after a mean follow-up of 34 years (range 03-134 years)
bull The level of sports was recorded in 23 studies or 635 (93) athletes
and included 286 competitive or professional athletes and 349 recreational athletes
bull Most commonly practiced sports were baseball (224 participants) tennis (104 participants) and golf (54 participants)
bull Overall rate of return to sport was 847 (95 CI 776-898)
including 659 (95 CI 549-754) at an equivalent level of play after 4 to 17 months but in professional and competitive athletes
499 (95 CI 353-646) returned to the same level of play
Kloucheet al AJSM 2015
Elite pitchers
bull No one returned to competitive pitching in the same season after rotator cuff surgery
bull Reynolds et al reported a median of 2 seasons of
pitching after debridement of partial thickness cuff tears
bull Mazoue and Andrews reported a mean of 07
seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair
Harris et al Sports Health 2013
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
13
Manual therapy amp CPM
bull Systematic review to determine effect of different
rehabilitation protocols on clinical outcomes by comparing early vs late mobilization approaches and continuous
passive mobilization (CPM) versus manual therapy after arthroscopic rotator cuff repair
bull 7 studies met all criteria and were included in the final
analysis Five studies compared early and late mobilization Two studies compared CPM and manual therapy
bull Current data do not definitively demonstrate a significant
difference between postoperative rotator cuff rehabilitation protocols that stress different timing of mobilization and use
of CPM
Yi et al Sports Health 2015
Early vs delayed AROM
bull Systematic review of articles published between January
2004 and April 2014 was conducted
bull Structural results were compared for early (lt6 weeks after surgery) versus delayed (ge6 weeks after surgery) active ROM
bull 37 studies (2251 repairs) were included in the analysis with 10 (649 repairs) in the early group and 27 (1602 repairs) in
the delayed group
bull Early active ROM was associated with increased risk of a structural defect for small and large RC tears
Kluczynski et al AJSM 2015
bull Randomized controlled trials that evaluated the effectiveness and safety of early and delayed motion for rehabilitation after arthroscopic rotator cuff repair
bull Four randomized controlled trials involving a total of 348 shoulders were included in meta-analysis
bull Two were rated as high quality and two were rated as moderate quality
Chen et al Int J Clin Exp Med 2015
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
14
Chen et al Int J Clin Exp Med 2015
bull Early motion after arthroscopic rotator cuff repair resulted in
a significantly greater recovery of external rotation from pre-operation to 3 6 and 12 months post-operation (P lt 005)
and forward elevation ability from pre-operation to 6 months post- operation (P lt 005) as compared to when motion
was delayed
bull But early motion resulted in non-significant excess (P gt 005) in the rate of recurrence compared to delayed motion
bull Statistically higher rating scale of the American Shoulder
and Elbow Surgeons (ASES) scores at 12 months post-operation (P lt 005) and healing rates (P lt 005) with
delayed motion after arthroscopic rotator cuff repair compared with early motion
Chen et al Int J Clin Exp Med 2015
Early vs Late ROM
bull No conclusive evidence to support delayed ROM
bull Consider risk and reward and factors such as age size of tear quality of tissue labral pathology etc
bull No two rehabs alike
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
15
Keys to Successful Rehab
bull Get the op report
bull Less is often more early on as the body seeks homeostasis
bull Listen to your patient amp their pain level
bull Master the art of stretching
bull Patient compliance
Rehab - SADDCE
Phase I - Weeks 0-4
bull Sling for comfort for up to 2 weeks
bull ROM PROM -gt AAROM -gt AROM with goal of 140 deg flex 40 deg ER at 0 ABD
bull No 9090 stretching for IRER
bull Pendulums pulley cane exercises
bull Grip strengthening but no resistive exercises
bull Heat beforeice after Rx
Rehab - SADDCE
Phase II - Weeks 4-8
bull ROM - increase FF IR and ER to full as tolerated with goal of 160 deg flex and 60 deg ER at 0 ABD
bull Joint mobs STM gentle posterior capsular stretching
bull Initiate light isometrics for RC and deltoid at side
bull Scapular activation exercises
bull Gradually move to theraband and light weights
bull Modalities prn
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
16
Rehab - SADDCE
Phase III - Weeks 8-12
bull ROM - stretching to restore full mobility
bull Isotonics for RC and scapular stabilizers
bull Diagonal patterns and overhead progression
bull Advance PRErsquos with increasing focus on eccentric exercises closed chain exercises and plyometrics
bull Gradual return to sport programming
Rehab - Arthroscopic Repair with Early ROM
Phase I - Weeks 0-4
bull Sling wabduction pillow outside PT for 4 weeks
bull PROM only to patient tolerance with goal of 140 deg flex 40 deg ER at 0 ABD ABD to 60-80 (no rot) and limit IR to 40 wshoulder in 60-80 deg ABD
bull Elbow at or anterior to mid-axillary line in supine
bull Pendulums but no pulley or cane exercises
bull Grip strengthening elbow wrist and hand ROM table slides
bull Isometric scapular stabilization
bull Heat beforeice after Rx
Rehab - Arthroscopic Repair with Early ROM
Phase II - Weeks 4-8
bull DC sling modalities prn pulley
bull ROM weeks 4-6 PROM to meet phase I goals and from
weeks 6-8 AAROM -gt AROM as tolerated
bull Gentle joint mobs (grade III)
bull AAROM supine (cane flexion hor ABDADD ER)
bull Submax isometrics at 0 ABD bw weeks 4 and 6
bull Scapular strengthening and AROM between weeks 6
and 8
bull If biceps tenodesis no biceps strengthening until week 8
bull Modalities prn
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
17
Exercise Videos
1Pendulums
2Pulley
3Ball stabs on floor
Isometrics
Scapular strengthening
bull Manual resistance by PT
bull Postural retractions
bull Isometric theraband shoulder extension with retractions
bull Serratus punch with cane
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
18
Rehab - Arthroscopic Repair with Early ROM
Phase III - Weeks 8-12
bull ROM - progress to full AROM wo pain
bull Posterior capsule stretching
bull Progress phase II exercises
bull Theraband walkouts
bull Initiate isotonics for RC and scapular stabilizers (usually no weight at first between weeks 8 and 10)
bull Light UBE
bull Modalities prn
Mobility amp Stretching
bull Teach self MFR for pecs lats and
posterior shoulder
bull Low load stretch
bull Daily as needed for
restricted motion
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
19
Stretching notes
bull Low load longer duration
bull 30 seconds (3-5x)
bull Do not stretch into or through pain
bull Modified sleeper amp cross body stretch
can be used (roll posteriorly 20-30 deg)
Exercise Videos
1Theraband walkouts
2Ball on wall
Rehab - Arthroscopic Repair with Early ROM
Phase IV - Months 3-6
bull ROM - Goal is full pain free motion
bull Advance RC and scapular strengthening with light
weights (typically no gt 4 bodyweight)
bull Progress to overhead exercises as indicated
bull Initiate functional andor sport specific between 14 and 16 weeks post-op once cleared by MD
bull Return to sports at 6 months if approved but may be
longer based on age degree of injury and demand of
sport (may be longer for throwers)
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
20
Exercise Videos
1RC post-op strengthening
2Advanced RC post-op strengthening
Prone Progressions
bull Extension and Abduction first
bull Low trap raise next
bull Advance to prone row with ER once good motion and control with HER in
seatedstanding position
bull Focus on cadence with good eccentric
control
Full Can vs Empty Can
bull Dominant shoulder MVIC tested wEMG for 3 exercises full
can standing empty can standing and prone hor ABD at 100 with full can
bull While all 3 exercises produced similar amounts of
supraspinatus activity the full can exercise produced significantly less activity of the deltoid muscles and may be
the optimal position to recruit the supraspinatus muscle for rehabilitation and testing
bull The empty can exercise may be a good exercise to recruit
the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the posterior deltoid muscle
Reinold et al J Athl Train 2007
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
21
Full Can vs Empty Can
bull Participants with SAIS (n = 28) performed 5 consecutive
repetitions of FC and EC exercises
bull Participants reported greater pain during the EC exercise vs the FC exercise
bull During the EC exercise participants were in greater
scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt thus decreasing
subacromial space
bull Scapular muscle activity was generally higher with the EC which may be an attempt to control the impingement-related
scapular motion
Timmons et al JSES 2015
External rotation
bull Often the weak link
bull DB vs theraband - consider the force
generation mismatch and phase of rehab
bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62
MVIC) and teres minor (67 MVIC)
Reinold et al JOSPT 2004
Strength Progression Guidelines
bull Size of tear
bull Number of tears
bull Quality of tissue
bull Concomitant pathology
bull Age amp physical demands of job
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
22
Workout Precautions
bull Overhead lifts
bull Dip flies and full
range push-ups
bull Heavy pressing
bull Ballistic loads
bull Certain Crossfit
exercises
Workout Modifications
bull Limit depth of pressing and flies to where elbow does not drop below plane of body
bull Pressing in scapular plane with unilateral loads to
integrate core (if done at all)
bull No dips
bull Limit upright rows height and use sparingly
bull No long lever abduction raises
bull Ratio of pulls to pushes should be 21
Return to Play
bull Assess ERIR strength ratio general
MMT FMS and UQYBT
bull Interval hitting and throwing programs
commence between 4 and 6 months
bull Timeline varies depending on patient
MD and activity or position
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
23
Upper Quarter YBT Video
Summary
bull Arthroscopic repair is current standard of care
bull Debride tears less than 50
bull Double-Row repair is superior to single-row technique
bull No definitive answer on early vs delayed motion but
use caution and do not go too fast
bull Protocols are basic blueprints so treat every patient as an individual always letting evidence pain and
progress guide clinical decision making
Contact Info
Brian Schiff PT OCS CSCS
wwwBrianSchiffcom
infoBrianSchiffcom
Twitter - brianschiff
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
24
ReferencesChen L Peng K Zhang D Peng J Xing F Xiang Z Rehabilitation protocol after arthroscopic rotator cuff repair early versus delayed motion Int J Clin Exp Med 2015 Jun 158(6)8329-38
Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25 years Orthopedics 2015 Jul 138(7)e631-e634
Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9
Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement syndrome Open Access J Sports Med 2014 Feb 28513-24
Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports Phys Ther 201141 296-303
References
Harshbarger ND Eppelheimer BL Valovich McLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil 2013 Nov22(4)313-9
Hein J Reilly JM Chae J Maerz T Anderson K Retear Rates After Arthroscopic Single-Row Double-Row and Suture Bridge Rotator Cuff Repair at a Minimum of 1 Year of Imaging Follow-up A Systematic Review Arthroscopy 2015 Jul 15 pii S0749-8063(15)00496-X doi 101016jarthro201506004 [Epub ahead of print]
Killian ML Cavinatto LM Ward SR Haviloglu N Thomopoulos S Galatz LM Chronic Degeneration Leads to Poor Healing of Repaired Massive Rotator Cuff Tears in Rats Am J Sports Med 2015 Aug 21 pii 0363546515596408 [Epub ahead of print]
Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704
Lambers Heerspink FO van Raay JJ Koorevaar RC van Eerden PJ Westerbeek RE van lsquot Riet E van den Akker-Scheek I Diercks RL Comparing surgical repair with conservative treatment for degenerative rotator cuff tears a randomized controlled trial J Shoulder Elbow Surg 2015 Aug24(8)1274-81
References
Louche S Lefevre N Herma S Gerometta A Bohu Y Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-Analysis Am J Sports Med 2015 Aug 27 pii 0363546515598995 [Epub ahead of print]
Matthewson G Beach CJ Nelson AA Woodmas JM Ono Y Boorman RS Lo IK Thornton GM Partial Thickness Rotator Cuff Tears Current Concepts Adv Orthop 20152015458786 doi 1011552015458786 Epub 2015 Jun 11
Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117
Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9
Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4
25
References
Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 2015
Sheps DM Bouilane M Styles-Trpp F Beaupre LA Saraswat MK Luciak-Corea C SilveiraA Glasgow R Balyk R Early mobilisation following mini-open rotator cuff repair a randomised control trial Bone Joint J 2015 Sep97-B(9)1257-63
Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4