Transcript
Page 1: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 2: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 3: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 4: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 5: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 6: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 7: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 8: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 9: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 10: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 11: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 12: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 13: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 14: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 15: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 16: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 17: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 18: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 19: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 20: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 21: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 22: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 23: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 24: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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

Page 25: Rotator Cuff Dysfunction: Surgical Intervention and ... · arthroscopic rotator cuff repair • 7 studies met all criteria and were included in the final analysis. Five studies compared

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


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