Wellness & Lifestyles Australia

ROTATOR CUFF REPAIR E-BOOK

prepared by

Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE ..................................................................................................... 2 INTRODUCTION .......................................................................................................... 3 SHOULDER ANATOMY ................................................................................................... 4 ROTATOR CUFF REPAIR ................................................................................................. 5

The operation .................................................................................................. 5 Indications ...................................................................................................... 5 Advice for after the operation .............................................................................. 5 Rehabilitation: Acute inpatient phase ..................................................................... 6 Rehabilitation: Weeks 2 - 6 ................................................................................. 10 Rehabilitation: Weeks 6+.................................................................................... 16

SUMMARY ................................................................................................................ 29 CONTACT US ............................................................................................................ 30

MANUAL LAST MODIFIED 4/11/2010

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IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation. Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances. To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action. Copyright Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.

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INTRODUCTION Welcome to the W&L series of e-books. You have chosen the edition on rotator cuff repair and rehabilitation. This resource will be beneficial for those who:

Anyone who is interested in the anatomy and biomechanics of the shoulder joint Anyone who has difficulties with their shoulder from degeneration or injury and wants to know

their options for maximum recovery Anyone who is wondering what a rotator cuff repair involves and when it would be appropriate Anyone who is participating in a rehabilitation program after shoulder injury or surgery and wants

a comprehensive guide to their exercises Anyone who is guiding someone through a rehabilitation program and wants to deliver

comprehensive and up to date information This e-book will cover information about the anatomy of the shoulder and the ways it is commonly damaged. It will also explain the different surgeries and what to do to maximise recovery. It also will accompany you from the days leading up to surgery until you fully recover with advice, answers and exercises. The information provided is up to date and follows industry standard. W&L recommend that you continue to consult your doctor and physiotherapist so that your progress can be monitored and program tailored to your specific requirements.

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SHOULDER ANATOMY Each shoulder joint includes three main bones: scapula (the shoulder blade) humerus (the arm bone which connects to the scapula) and clavicle (the collarbone which connects the shoulder with the sternum). These joints are held in place by many muscles and ligaments.

Diagram taken from: National Institute of Arthritis and Musculoskeltal and Skin Diseases (2009), Sports Injuries, accessed 28 October 2010 on

http://www.niams.nih.gov/Health_Info/Sports_Injuries/default.asp The most obvious joint is the glenohumeral joint, where the arm attaches to the body in a shallow ball and socket joint. This shallow joint allows for large degrees of movement and relies heavily on muscles and other structures to support the joint. There is a joint capsule which surrounds the glenohumeral joint like a sock with the toes cut off. This capsule has four main muscles around it called the rotator cuff muscles. These muscles have a big role in stabilising the shoulder when the shoulder is moving and work together to hold the humerus in the joint socket. The tendons of these muscles are vulnerable to degeneration around the capsule.

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ROTATOR CUFF REPAIR

The operation Rotator cuff repairs involve mending the injured tendons of the rotator cuff muscles and removing any structure which may be causing injury to the tendons. Damaged tendons are repaired by removing any injured tissue and then either rejoining the tendons or attaching the tendons to the bone directly. Sometimes the rotator cuff tendons are damaged by rubbing against rough peaks of bone, called spurs. If this has been the case, the surgeon will also smooth over the bone to reduce further damage. Rotator cuff repairs can be done by arthroscopy (refer to arthroscopy section for further detail) but may also require open surgery depending on the extent of the damage.

Indications

This surgery is usually indicated: Following trauma, such as a fall, where the rotator cuff was injured. With pain from rotator cuff damage which can not be managed with painkillers or other physical

treatments. With loss of function associated with damage to the rotator cuff.

Advice for after the operation

It is normal to experience pain after your surgery and it will usually be worse at night time. Swelling and bruising usually form and will gravitate down the arm. Take pain relief and continue to ice the shoulder to reduce swelling and discomfort. You can massage the arm (not the shoulder) to help reduce swelling. Lay on your good side for at least 20 minutes, three times a day with your operated arm resting

under pillows to reduce swelling. It is important to move your elbow, wrist and fingers on your operated arm so that they dont

develop stiffness. Keep your sling on at all times except for doing exercises and washing. Do not lift your arm or your forearm away from your body. Do not lie on your operated side or do any overhead work for at least 3 months. You will not be able to drive until you are able to lift your arm in front of you to shoulder level.

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Rehabilitation: Acute inpatient phase Aim: To reduce stiffness in other joint and to maintain strength Posture correction reverse your hospital bed posture by straightening your back, tucking in your chin, raising your breast bone and drawing your shoulder blades downward and together. Repeat this throughout the day and while doing exercises

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Elbow mobilisation take off your sling, ensuring that your forearm is kept next to your stomach. Bend and straighten your elbow (using your other hand to help if needed) 10 times with your palm facing up and then 10 times with your palm facing down.

Wrist mobilisation move your wrist in circles, 10 clockwise and 10 anticlockwise 3 times a day.

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Hand mobilisation clench and open your hand 10 times hourly, this will help prevent swelling.

Pendulum in sling place your good hand on a surface and lean your body forward so that your arm gently swings forward in the sling. Ensure that your elbow is no more than a hands length away from your body. In this position, use your body to draw small circles, 10 clockwise and 10 anticlockwise.

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Shrugging shrug your shoulders up and down, then forwards and backwards, doing 10 in each direction.

Note: After exercise it is best to apply an icepack to your operated shoulder, leaving it on for 10 minutes and then off for 10 minutes before putting it back on for 10 minutes.

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Rehabilitation: Weeks 2 - 6 Massage after your stitches have been removed you can massage along the scar and any muscles which are feeling tense or tender. Pendulum out of sling with your sling off, place your good hand on a surface and lean your body forward so that your arm gently swings forward with your elbow straight. In this position draw small circles, 10 clockwise and 10 anticlockwise. Note: If you check with your therapist, then you can add forwards and backwards swinging and side to side swinging.

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Passive shoulder lifting lie on your back with the sling off and hold your operated elbow with your good arm. Use your good arm to lift up your operated arm off of your chest, hold for 3 seconds and then lower it back down. Repeat 10 times. Do not do any of the work with your operated arm, keep it as relaxed as possible.

Passive external rotation have both of your arms by your side and elbows bent to 90 holding onto a ruler. Use your good arm to push your operated arm out to the side and hold for 3 seconds before returning. Repeat 10 times. Do not let your operated side do any of the work.

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Passive Abduction holding the ruler in both hands, have your wrists rest on the front of your hips and your forearms resting on your stomach. Use your good arm to push your operated arm away from your side very slowly until you start to feel and increase in pain. Hold for 3 seconds and repeat 10 times. Do not let your operated side do any of the work.

Hand behind back with your operated arm, reach your hand towards your buttock until you feel and increase in pain and hold for 5 seconds, repeat 10 times.

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Isometric adduction place a small rolled towel between your elbow and side. Squeeze your elbow to your side for 5 seconds and release, repeat 10 times.

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Isometric flexion position your operated arm as if you were reaching out to give a handshake but only to the point where you feel an increase in pain. Form a fist with your hand on the operated side and cup your other hand around it. Push forwards with your operated arm but counteract this movement with your good hand so that your operated arm does not move. Alternatively, push your operated arm against a wall so that it doesnt move. Hold for 5 seconds and repeat 10 times.

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Isometric extension in the same handshake position, draw your operated arm backwards until you feel an increase in pain. At this position, push the back of your elbow against a wall without moving your arm or letting your body be pushed forward. Hold for 5 seconds and repeat 10 times.

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Rehabilitation: Weeks 6+ Aim: To recover the range of movement available in your shoulder which was lost from being kept in a sling. Advice:

It is normal to find that you have difficulty moving your shoulder, in some directions more than others.

Exercises will help to regain this function but they should be done slowly with control, especially at first.

Spread out your exercises as much as possible, doing little bits at a time. If your shoulder is aching, this often means that it has been overworked and should be rested and

iced. Ice your shoulder for 10 minutes after exercising.

Advanced pendulum exercises place your good hand on a surface and lean your body forward. In this position draw large circles, 10 clockwise and 10 anticlockwise. From the hanging position, swing your arm forward and hold for 5 seconds before dropping back. Repeat this 10 times and try in different directions.

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Forward pulleys with posture correction (see rehabilitation: acute inpatient phase) either sit or stand with the pulley rope in your hands (you can drape the rope over a pergola beam or something similar). Pull down with your good arm to raise your operated arm as much as tolerated and hold for 3 seconds before lowering. Try to use the muscles on your operated arm to assist the lift so that you rely less on the pulley rope. Repeat 10 times.

Sideward pulleys repeat as the forward pulleys exercise but bend your elbows and have your arms out to the side so that when you pull with your good arm, the operated arm will lift to the side.

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Hand behind back with pulleys repeat as with the other pulley exercises except have the good arm with the pulley in front of you and the operated arm behind you. Pull with the good arm and raise the operated arm higher up the back. Alternatively, a towel can be used with the good arm pulling at the front and the operated arm lifting behind the back.

Overhead stick laying on your back, pull your shoulder blades together and downward. With a stick held between both hands, lift your arms overhead until tolerated and hold for 3 seconds before returning. Repeat 10 times.

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Diagonal stick repeat as with overhead stick, however have the operated arm going overhead and out towards the side. Repeat with the good arm going overhead and out to the side.

External rotation stick repeat as with overhead stick, however have the upper part of the operated arm resting on the ground with the forearm perpendicular to the floor. Use the stick and your good arm to push the forearm towards your head on the floor.

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Arm circles on back lie on your back with an empty hands or a light weight and raise your arm straight directly over your head. Gently do 10 circles clockwise and then 10 anticlockwise.

Hand behind back lying down while laying on your back, position the hand of your operated arm up as far as you can behind your back. Bend the knee on the opposite side and role your body towards your operated side. Hold the stretch for 10 seconds and repeat 10 times.

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Arm stretch with towel lying down lie on a rolled up towel going across the base of your shoulder blades. Pull your shoulder blades down and raise your arms above your head, stretching away from you feet. Hold for 20 breaths. Repeat with your arms out to the side and palms facing up.

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Spider walking front stand face on to a wall and place your hands of the wall with your elbows bent. Crawl your fingers up the wall until you feel discomfort. Take your hands off the wall and keep it level there for 3 seconds before placing it back on the wall on the same spot. Try to crawl up further until you are unable to replace your hand at the same level.

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Spider walking side repeat spider walking front exercise, but this time stand side on to the wall and crawl your hand up out to your side. Make the exercise harder by standing further away from the wall and straightening your elbow more.

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External rotation stand at a doorway with your hand on the frame and your upper arm held against your body (you can use good arm to assist). Twist your body away from the operated arm until you feel a stretch. Hold for 10 seconds and repeat 10 times. Make this exercise harder by bringing you arm further up the door frame so that your upper arm comes away from your body.

Horizontal flexion with your operated arm up in front of you, use your good arm to pull your elbow across your body and hold the stretch for 10 seconds. Repeat 10 times. Make this exercise harder by raising your operated arm higher.

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Ball exercises on table stand at a table with shoulder blades down and back. Use the hand of your operated arm to hold a ball on the table. Twist the ball from 9 oclock to 3 oclock and back, repeat 10 times. Repeat the exercise standing side on.

Ball exercises on wall as with the ball exercises on the table, hold onto the ball against a wall and twist from 9 to 3 oclock. Repeat standing side on.

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Push ups against wall place both hands against the wall at shoulder height and do 10 wall push ups. Progress the exercise by holding onto a ball against the wall, then doing push ups with only one arm and then one arm with a ball. Repeat the exercise side on with one arm.

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Shrugging with arms out 45 from your side shrug you shoulders up and hold for 5 seconds, repeat 10 times. Make this exercise harder by having weights in your hands.

External rotation in side lie lie on your good side with the elbow of your operated arm bent to 90. Slowly lift your forearm with your upper arm against your side and slowly lower again. Repeat 10 times.

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Resisted flexion lying on your back, hold a Theraband in both hands and place your good hand by your hip. Pull with your operated arm diagonally upwards and return to your opposite hip with control. Repeat 10 times. Make the exercise harder by shortening the Theraband length between your hands.

Bilateral external rotation hold Theraband in both hands, squeeze your shoulder blades together and have your upper arms in by your sides. Turn your forearms away from each other and hold for 5 seconds before bringing your arms back slowly. Repeat 10 times.

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SUMMARY In summary, the shoulder is a complicated joint with a high reliance on the muscles and tendons surrounding it. Rotator cuff repairs are a useful surgery to improve the function of the shoulder joint after the soft tissue structures have been damaged. Exercises will play an important role in a successful and quick recovery. It is important to not overdo exercises, instead aim to do your exercises frequently with a little bit at a time. Use ice and painkillers appropriately to manage your symptoms and avoid using your arm for heavy lifting. In all exercises, having your shoulder blades properly positioned so that they are drawn together and downward is important for moving your shoulder correctly with control. Please use this resource as a guide to your rehabilitation in consultation with your surgeon and therapist. All the best for a speedy recovery, The W&L Team

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CONTACT US Wellness & Lifestyles Australia 2/59 Fullarton Road, Kent Town SA 5067 P: +61 8 8331 3000 F: +61 8 8331 3002 E: contact@wellnesslifestyles.com.au W: www.wellnesslifestyles.com.au www.wleducation.com.au W&L services include: Physiotherapy Aged Care Funding Instrument (ACFI) Consultancy Podiatry Speech Pathology Dietetics Diabetes Education Occupational Therapy Psychology Physiotherapy Aide Diversional Therapy Aromatherapy Natural Therapies Massage Exercise Physiology Educational Training Staff Wellness Program Locum Services Medicare Billing Aged Care Funding Instrument Documentation Online Training W&L products include: Posters E-books E-learning modules Audio/visual Hot tips/articles