Rotator Cuff Arthropathy

Andre Le LeuPhysiotherapy Clinical Specialist

Shoulder and Elbow UnitStanmore, UK

Contents

• Anatomy• Pathology• Sub-acromial Impingement Syndrome• Clinical Assessment• Treatment methodology

Anatomy

Anatomy

Subscapularis

Corocoid

Rotator interval

Acromium

Supraspinatus

Infraspinatus

Teres minor

Glenoid

AnteriorZone

Posterior/SuperiorZone

NB: Subacromial Bursa not illustrated here but a critical element

Biomechanical Considerations

Suprasp.

Infraspin

Subscap

Teres Minor

Deltoid

Cable Theory

Anterior Pillar Posterior Pillar

subscap

LHBT Supra/infra sp.

Teres Minor

Rotator Cuff Tendonopathy40 yrs 60 yrs 80 yrs +50 yrs

‘Repetitive strain’ overuseBiomechanical impingementAngiogenesisUp regulation of fibroblast activity

PHYSIOTHERAPY +++++++

Intra-substance tearsPlasma enrichmentSurgical debridement

PHYSIOTHERAPY +++

Rotator cuff tearsRehab Surgery

GENTLE PHYSIOTHERAPY

Salvage opsTendon transfersConstrained TSR

FUNCTIONAL REHAB

Rotator Cuff Examination

• No test is absolute and definitive • Tests are merely a provocation symptoms

rather than a confirmation of diagnosis (Lewis, 2008)

• 90% of diagnoses are made from the patient history (Malone, 2005)

Examination

• Look…. Postural alignment

Bony landmarksMuscle bulk/atrophyGeneral (scars, limb perfusion etc)

• Feel….Palpation (joint lines, muscle belly, ligaments/bursa)

• Move….Active movement, passive movement, resistance

DO NOT FORGET NEUROVASULAR COMPONENTS / CLEARING TESTS

Special Tests

• Supraspinatus– Jobes Test 90 degrees scaption

Internal rotation (thumb down) Without resistance then with resistance Pain and or weakness

Modification to start in thumbs up and run resistance testing through range to include rotator interval component.

- Initiation of Abduction testing Arm by the patients side Palpate the Humeral Head Assess resisted abduction Weakness, pain, superior translation of humeral head are all indicative of a positive test

Subscapularis• Gerber’s Lag sign

As above but the therapist positions the hand ways from the spine and the patient must hold this position. (80% sensitivity for small tears)

• Gerber’s lift off testHand behind the back at 90 degrees elbow flexionThe patient must keep the arm away from the spineThe Therapist can add resistance (90% sensitivity for weakness or pain)

• LaFosse belly press Hand rests on belly with wrist at neutral away from the forearm Held away from the body. The patient pulls the entire arm into the stomach (watch for drop of elbow or wrist),

can also add therapist resistance to the outside of the elbow Good for patients with restrictions to movement Recruitment of P.major in 25% clouds the examination

Infraspinatus and Teres Minor

• Resisted testing1. External rot lag sign (ERLS) with arm at waist the

therapist positions arm in full external rotation and the lets go while the patients attempts to hold this position. You can then add therapist resistance and required looking for pain/weakness.

2. Patient Holds arms in 60 degrees scaption with elbows at 90 degrees. Patient must resist internal rotation movement against the therapist.

Pain and or weakness can be indicative of posterior cuff insufficency.

Infraspinatus and Teres Minor• Patte’s Test

90 degrees of abduction and external rotation, the patient must hold against resistance.

Watch for correct scapulo-thoracic alignment Can test eccentric control element

• Hornblowers Sign Arm held in 90 degrees scaption with hand in front of the mouth (supination).

Patient must move the arm out into external rotation against gravity, however the therapist can also look to add resistance.

• Hornblowers lag sign Arm is positioned at 90 degrees in scaption with full external rotation by the

therapist. The Patient must the hold this position once the therapist lets the arm go. A positive drop sign is indicative of a massive posterior cuff tear.

Biceps tendon• Check for Popeye sign (rupture of LBHT)• Speeds test

Patient holds straight arm in supination at 90 degrees flexion and tries to elevate the arm against the therapists resistance. Pain indicative of provocation.

90% Sensitivity and 15 % specificity (Malone 2005)

• LaFosse AERS test (abduction, ext rot, supination) Arm is held at 90 degrees abduction and externally rotated with elbow at 90

degrees in pronation. The Therapist provides resistance as the patient supinates the arm Pain is indication of possible biceps irritation or SLAP tear

• Yergason’s test – arm by side and elbow at 90 degrees, the therapist holds the patients hand and resists

the patient moving into supination while palpating the LHBT. – Look for pain and or subluxation of tendon from bicepital groove

Shoulder Impingement Syndrome

Impingement Tests

• Neer’s Test– Therapist stands behind the patient and stabilizes the scapular. The

holds the arm in ‘thumbs down’ in full elbow extension. – The maneuver is to the elevate the arm into f.flexion– Provocation of pain (80% specificity for bursa and cuff problems

Malone et al)

• Hawkins (Kennedy) Test– Therapist holds he arm in the plane of the scapular with the elbow at

90 degrees.– The hand is put into a thumbs down position and then the arm is

medially rotated, a positive test provokes pain/restriction of movement (90% sensitivity, Malone et al)

Acromioclavicular joint

• Pain on palpation • Pain at end range abduction, hand behind

back• Scarf test

» Pain provocation with horizontal adduction» NB restriction of movement may be due to posterior

capsular stiffness esp. if scapular is held in retraction

Innervation• Suprascapular nerve

• Nerve to Subscapularis

• Axillary or Circumflex nerve

• Lateral Pectoral Nerve

• Autonomic Nervous System (LBHT)

Practical Session

• Basic Assessment

• Provocation Testing

• Where to Start Rehab?

Indications forShoulder Replacement Surgery

Indications for surgery

• Pain• Loss of function and ROM• Quality of life• Failed conservative management• Age related considerations

Indications for Primary TSR

Arthritic joint pathology

Neer Classification System for proximal humeral fractures

Pathology

AVN Tumours

Infection

Types of Shoulder Prosthesis• Fully constrained = For severe arthritis of the shoulder

and destruction of the rotator cuff. Basically a salvage procedure.

• Semi constrained = To prevent superior subluxation of the humeral prosthesis when the patient has joint arthritis and rotator cuff insufficiency.

• Un Constrained =Joint arthritis with good rotator cuff function.

• Surface replacement= one articular surface involved

Cemented or Uncemented?

Cemented• Reduced pain reported

• Increased mobility

• Senior population

• Less physically demanding lifestyle

Uncemented• Avoid loosening of parts

• Scope for revision in younger person

• Active lifestyle

• Extended recovery period

RNOH Philosophy

• Bone Stock & Rotator Cuff

– Good BS / good RC = unconstrained TSR

– Good BS / poor RC = Constrained

– Poor BS / good RC = CAD-CAM stem

– Poor BS / poor RC = CAD-CAM glenoid/stem

Surface Replacement

Unconstrained

Modular (no glenoid liner)

Cemented or uncemented

Sulzar TSR – with glenoid liner (cemented)

Glenoid screw and Biomet Humeral Component

Constrained

Reverse Delta-3

Constrained

Reverse Fixed Fulcrum (Bayley-Walker)

Constrained

CAD CAM

RNOH Rehabilitation guidelines

Weak and smooth shoulderStiff shoulder

Post operation immobilisation

Abduction pillow polysling

Rehab Guidelines All of this will vary according to the individual

Phase 1 – Initial RehabOptimise tissue healing (time specified)

Pain control “SMOOTH AND WEAK”Use of slingNo ER>neutral/20 degreesA-A/Passive elevation<90 degreesNo active use of UL or strengtheningNo HBB or cross bodyEducation

Milestones for next stageAchieved time specific goalsFor X-rays to show osseo-integrationAllowed ROM achievedReduced painAdequate scapula control

Early phase day 1 -6/52 exercise

Active assisted GHJ FF 90 ISOMETRIC ER IN NEUTRAL

ISOMETRIC IR IN NEUTRAL Carer performing the exercise

Early phase day 1 -6/52 exercise

Start position with shoulder supported

Active assisted GHJ ER to neutral start…

Carer performing the exercise

End position of exercise

Phase 2 – Early Recovery (approx 6 weeks – 4 months)Decrease sling use

Start light activity at waist level

Increase ROM

Optimise normal movement patterns

No exercises that increase pain

No active anti-gravity work until RC rehabilitated

Deltoid Programme for Constrained TSR

Milestones for next stageNo sling

Minimal pain

Passive ROM: elevation>90 and ER>30

RC stabilises within available ROM

Functional Triangle

Phase 3 – Late Recovery (approx 5 months – 12 months)Increase strength and endurance to functional level required

No exercises that increase pain

No heavy lifting above shoulder level

Milestones for DischargeReduced pain from pre-op status

Achieved functional goals

Expected outcomes Unconstrained – Light to moderate use at waist, shoulder and above shoulder level

Constrained – Light use at waist level and

towards shoulder height if possible

May take 12-24 months to achieve

Rehabilitation Guidelines

• www.rnoh.nhs.uk• Follow link to CLINICAL SERVICES• Click on Physiotherapy• Click on SHOULDER AND ELBOW UNIT• Select Guideline for exercise information