rehabilitation of rotator cuff tears - smertebehandling · rehabilitation of rotator cuff tears: a...

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Rehabilitation of rotator cuff tears: A literature review and evidence-based rehabilitation

protocol

Prof dr Ann Cools, PT, PhDDept Rehab. Sciences & Physiotherapy

Ghent University, BelgiumA Cools RC tears 2016

Ann Cools - Nice June 2016

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Epidemiology(Simon Lambert, EUSSER conference London 2012,Teunis et al. Syst Rev JSES 2014)

A Cools RC tears 2016

Classification of RC tears (Al-Hakim S&E 2015)

Normal rotator cuff


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Common tear of the ageingcuff

Remains stable because the fibrous endoskeletonremains attached

Often acceptable restoration of function and pain afterinitial onset


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The predominantly unstablecuff lesion

Cable is slack and retractsmedially

Rotator interval widensallowing humeral headescaping anterosuperiorly



The predominantly weak cufflesion

Tear extends posteriorly, through the posterior pillar

Weak external rotation

Slight posterio-superior subacromial shift


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Massive rotator cuff tear

All 3 muscles involved

Unstable, weak and painful

Often lesion LHB, synovitis, joint arthropathy


Classification of rotator cuff tears


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How active are the elderly?

Master Athletes = “Active individuals aged 50yrs or older, who desireoptimal levels of performance or wish to exercisefor general health and have high expectations forsports medicine care, including return to sport or activity after injury”

(Selected Issues for the Master Athlete and the Team Physician:A consensus statement. Med Sci Sports Exc 2010)


Exercise as a treatment for RC full thickness ruptures(Systematic Review Ainsworth & Lewis, BJSM 2007)

– Exercise therapy, defined as strengthening andstretching, when included as a part of a treatment program, has a beneficial effect for patients who have symptomatic shoulders and radiological or arthroscopicevidence of full thickness RC tears

– Not possible to determine if exercise alone or combinedwith other interventions offer the greatest benefit

– Time-recommendations: 3-18 months


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Exercise as a treatment for RC full thickness ruptures(Kuhn MOON study JSES 2013)

– Large multi-center Case Series study (N=452)

– Conservative treatment following specific protocol

– Follow-up 6-12 weeks with 3 options: (1) cured, (2) better, continue program, and (3) no better, offered surgery

– Final follow up 1-2 year

– Sign improvement of patient-reported outcomes

– 75% successful, <25% go to surgery

– Cut off point for “success/failure” +/- 12 weeks


Exercise as a treatment for RC full thickness ruptures(Kukkonen J Bone Joint S 2015, Ketola et al. 2016)

• RCT: (1) physiotherapy, (2) acromioplasty + physiotherapy, (3) RC repair, acromioplasty + physiotherapy

• No group differences at finalfollow-up 12 months


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General Guidelines for rehabilitation

• Capsular mobilization to increase ROM• Stretching after capsular mobilization• Maximize RC strength• Maximize scapular position/motion as part of the

scapulohumeral rhythm• Change workouts: lighter weights, different positions….

A Cools RC tears 2016(Selected Issues for the Master Athlete and the Team Physician:A consensus statement. Med Sci Sports Exc 2010)

Personal Experience

Patients often have deficient rotator cuff: valueof cuff training?

Let’s try to optimize function without focussingtoo much on the structures…

Re-education of daily and athletic activities withthe purpose to postpone the final match…


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Conservative treatment RC tears (partial, irreparable)

TREATMENT GOAL

optimize function, in particularelevation above shoulder height ,

with limited load on the RC


“structure”-based versus “function” based rehab

Based on structure Based on function

Ann Cools - Nice June 2016

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Scientific base for Treatment Strategy(Uhl PM&R 2010, Gaunt et al. 2010, Levy JSES 2008, Ainsworth et al. Sz&E 2009, Murphy et al. JSES 2013)


Exercise program for RC tears

2 exercises- semi-closed elevation exercises +/- 9

progressions (Uhl et al. 2010, Lewis 2016, Gaunt et al. 2010)

- “ant deltoid” exercises +/- 5 progressions (Levy et al. 2008, Ainsworth at al. 2009)


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Semi-closed chain elevation exercises

1. Closed chain pendulum exercises

2. Bilateral bench slide < 90°

3. Unilateral bench slide < 90°

4. Unilateral bench slide > 90°

5. Uniletaral bench slide > 90° + resistance

6. Wall slide

7. Wall slide + resistance

8. Wall slide + resistance + open chain @ max elevation

9. Wall slide – resistance + open chain @ max elevation


Semi-closed chain exercises without/with resistance (1)


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“anterior deltoid” program

1. Passive2. Active – weight3. Active + weight4. Increasing inclination angle trunk5. Seated – weight6. Seated + weight


(Levy et al. JSES 2008) A Cools RC tears 2016

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(Levy et al. JSES 2008) A Cools RC tears 2016

EMG in SS < 10% MVC


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3 stages of exercises:

1. Passive

2. Active

3. With resistance andincrease inclination A Cools RC tears 2016


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Both: US + advise + steriod injection

A: + exercise program

Ex = Levy program

Limitation: no comparison withother ex program


POSTOPERATIVE TREATMENT after RC repair

Factors affecting the postoperative rotator cuff healing andrehabilitation program:

1. Demographic factors (younger age, male)

2. Clinical factors (no diabetes, no obesity, no smoking, more sports activity and ROM pre-op)

3. Factors related to cuff integrity (size of the tear, less fattyinfiltration and retraction)

4. Factors related to surgical procedure (no concomitant biceps of AC procedures)

(Fermont et al. Prognostic factors for successful recovery after arthroscopicrotator cuff repari: a systematis literature review JOSPT 2014;44(3):153-163)


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GOALS of the rehabilitation (Thigpen et al. JSES 2016: Consensus statement on rehab after RC repair)

Protect the repairPromote healingGradually restore ROMGradually restore muscle strengthGradually restore functionA Cools RC tears 2016

Protect the repair

Soft tissue-to-bone healing is slow: starts withformation of fibrovascular tissue interface between tendon & bone (Rodeo JBJS 1993)

At least 12 weeks of healing is necessary allowingpull-out strength of the repair (Sonnabend JBJS 2010)


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Factors that improve tendon-to-bone healing:

• Pressure (Weiler Arthr 2002)

• “Tendon” immobilisation (Ghodadra JOSPT 2009)

• Positioning (abduction / scapular plane) (HatakeyamaAJSM 2001)

(Ghodadra NS et al. Open, Mini-open and all-arthorscopic rotator cuff repair surgery:indications and implications for rehabilitation JOSPT 2009)


Immobilisation: Risk for frozen shoulder…

incidence of 5% stiff shoulder after RC repair, with risk factors: <50y, workers compensation claim (Huberty Arthr 2009, Saccomanno

KSSTA 2016) + important risk factor is pre-operative stiffness (Evans Bone Joint 2015)

Sling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in increased long-term stiffness and may improve the rate of tendon healing. (Parsons JSES 2010)


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Early mobilisation: Risk for re-tear…

Strong evidence that early initiation of rehabilitation and functional loading does not adversely affect clinical outcome (Syst Review Littlewood S&E 2015)

Early ROM exercises accelerate recovery, but are likely to result in improper tendon healing in shoulders with large-sized tears (meta-analysis of RCT Chang AJSM 2014)


Summary…

Individualized choice of rehabilitation program based on risk factors since no single rehabilitation protocol in general is superior to another (Chang AJSM 2014, Thomson et al. 2016)

In at-risk patients (with calcific tendonitis, adhesive capsulitis, labral repair), a postoperative rehabilitation regimen that incorporates early closed-chain passive overhead motion can reduce the incidence of postoperative stiffness after arthroscopic rotator cuff repair. (Koo Arth 2011)


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What after surgery? (Antoni et al. 2016)


What after surgery? (Antoni et al. 2016)


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What after surgery? (Schumann et al. AJSM 2010, Bülhoff 2015)



What after surgery? (Schumann et al. AJSM 2010, Bülhoff 2015)

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Take home message

Take care of the degenerativechanges in the shoulder, but…

Remind you often have to dealwith an active elderly patient

There is still hope after shoulderarthroplasty!


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(Gent, Belgium)A Cools RC tears 2016

rehabilitation of rotator cuff tears - smertebehandling · rehabilitation of rotator cuff tears: a...

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