rotator cuff arthropathy

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Rotator Cuff Arthropathy. Andre Le Leu Physiotherapy Clinical Specialist Shoulder and Elbow Unit Stanmore, UK. Contents. Anatomy Pathology Sub-acromial Impingement Syndrome Clinical Assessment Treatment methodology. Anatomy. Anatomy. Acromium. Rotator interval. Supraspinatus. - PowerPoint PPT Presentation

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  • Rotator Cuff ArthropathyAndre Le LeuPhysiotherapy Clinical SpecialistShoulder and Elbow UnitStanmore, UK

  • ContentsAnatomyPathologySub-acromial Impingement SyndromeClinical AssessmentTreatment methodology

  • Anatomy

  • Anatomy SubscapularisCorocoidRotator intervalAcromiumSupraspinatusInfraspinatusTeres minorGlenoidAnteriorZonePosterior/SuperiorZoneNB: Subacromial Bursa not illustrated here but a critical element

  • Biomechanical ConsiderationsSuprasp.InfraspinSubscapTeres MinorDeltoid

  • Cable TheoryAnterior PillarPosterior PillarsubscapLHBTSupra/infra sp.Teres Minor

  • Rotator Cuff Tendonopathy40 yrs60 yrs80 yrs +50 yrsRepetitive 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 ExaminationNo 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)

  • ExaminationLook. Postural alignmentBony 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 TestsSupraspinatusJobes Test 90 degrees scaption Internal rotation (thumb down) Without resistance then with resistance Pain and or weaknessModification 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

  • SubscapularisGerbers 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)

    Gerbers 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 MinorResisted 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 MinorPattes 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 tendonCheck 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 tearYergasons 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 TestsNeers TestTherapist 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.flexionProvocation of pain (80% specificity for bursa and cuff problems Malone et al)Hawkins (Kennedy) TestTherapist 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 jointPain on palpation Pain at end range abduction, hand behind backScarf testPain provocation with horizontal adductionNB restriction of movement may be due to posterior capsular stiffness esp. if scapular is held in retraction

  • InnervationSuprascapular nerve

    Nerve to Subscapularis

    Axillary or Circumflex nerve

    Lateral Pectoral Nerve

    Autonomic Nervous System (LBHT)

  • Practical SessionBasic Assessment

    Provocation Testing

    Where to Start Rehab?

  • Indications forShoulder Replacement Surgery

  • Indications for surgeryPainLoss of function and ROMQuality of lifeFailed conservative managementAge related considerations

  • Indications for Primary TSR

    Chart1

    22

    18

    11

    9

    9

    4

    2

    Number

    Foglio1

    IndicationsNumber

    Fracture of HH22

    O.A.18

    R.A.11

    Avascular Necrosis of HH9

    R/C Arthropathy9

    Capsulorraphy Arthropathy4

    Unstable shoulder2

    75

    Foglio1

    Number

    Indications for Primary Shoulder Replacement

    Foglio2

    Foglio3

  • Arthritic joint pathology

  • Neer Classification System for proximal humeral fractures

  • PathologyAVN TumoursInfection

  • Types of Shoulder ProsthesisFully 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?CementedReduced pain reported

    Increased mobility

    Senior population

    Less physically demanding lifestyleUncementedAvoid loosening of parts

    Scope for revision in younger personActive lifestyle

    Extended recovery period

  • RNOH PhilosophyBone Stock & Rotator CuffGood BS / good RC = unconstrained TSRGood BS / poor RC = ConstrainedPoor BS / good RC = CAD-CAM stemPoor BS / poor RC = CAD-CAM glenoid/stem

  • Surface Replacement

  • UnconstrainedModular (no glenoid liner)Cemented or uncementedSulzar TSR with glenoid liner (cemented)Glenoid screw and Biomet Humeral Component

  • ConstrainedReverse Delta-3

  • ConstrainedReverse Fixed Fulcrum (Bayley-Walker)

  • ConstrainedCAD CAM

  • RNOH Rehabilitation guidelinesWeak and smooth shoulderStiff shoulder

  • Post operation immobilisationAbduction pillowpolysling

  • Rehab Guidelines All of this will vary according to the individualPhase 1 Initial RehabOptimise tissue healing (time specified)Pain controlSMOOTH AND WEAKUse of slingNo ER>neutral/20 degreesA-A/Passive elevation
  • Early phase day 1 -6/52 exerciseActive assisted GHJ FF 90ISOMETRIC ER IN NEUTRALISOMETRIC IR IN NEUTRALCarer performing the exercise

  • Early phase day 1 -6/52 exerciseStart position with shoulder supportedActive assisted GHJ ER to neutral startCarer performing the exerciseEnd position of exercise

  • Phase 2 Early Recovery (approx 6 weeks 4 months)Decrease sling useStart light activity at waist levelIncrease ROMOptimise normal movement patternsNo exercises that increase painNo active anti-gravity work until RC rehabilitatedDeltoid Programme for Constrained TSRMilestones for next stageNo slingMinimal painPassive ROM: elevation>90 and ER>30RC stabilises within available ROMFunctional Triangle

  • Phase 3 Late Recovery (approx 5 months 12 months)Increase strength and endurance to functional level requiredNo exercises that increase painNo heavy lifting above shoulder level

    Milestones for DischargeReduced pain from pre-op statusAchieved functional goals

    Expected outcomes Unconstrained Light to moderate use at waist, shoulder and above shoulder levelConstrained Light use at waist level and towards shoulder height if possible

    May take 12-24 months to achieve

  • Rehabilitation Guidelineswww.rnoh.nhs.ukFollow link to CLINICAL SERVICESClick on PhysiotherapyClick on SHOULDER AND ELBOW UNITSelect Guideline for exerc