Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
CLINICAL COMMENTARY
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1
Orthopaedic Surgeon, Rush University, Department of Orthopaedic Surgery, Chicago, IL. 2 Orthopaedic Surgeon, Naval Medical Center, Department of Orthopaedic Surgery, San
Diego, CA. 3 Associate Clinical Director, Champion Sports Medicine, A Physiotherapy Associates Clinic, Birmingham, Al; Rehabilitation Consultant, Tampa Bay Rays Baseball
Team, Tampa Bay, FL. Address correspondence to Dr Neil S. Ghodadra, 1653 West Congress Pkwy, 1471 Jelke Bldg, Chicago, IL 60612. Email: neil_ghodadra@rush.edu
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 81
CLINICAL COMMENTARY
suture technique is employed. An approximately 1.5-cm bridge of hard cortical bone is preferred between the medial
and lateral drill holes, with the lateral
hole exiting cortical bone distal to the
greater tuberosity to optimize tendonbone healing and xation strength. 9 A
braided nylon suture is passed through
the bony tunnels, then through the tendon, with at least a 1-cm cuff of tissue.
A simple suture technique is used for repair. A locking-stitch technique, known
as the modied Mason-Allen stitch, is
also often used for better holding power,
especially when the quality of the rotator cuff tissue is compromised.27 Multiple
other suture techniques and open repair
suture and/or anchor congurations have
been described.
Deltoid reattachment to the acromion
is a critical component of open rotator
cuff repair, with specic implications for
postoperative rehabilitation. A strong and
meticulous repair of both the supercial
and deep deltoid fascial layers is essential
to avoid postoperative dehiscence during
rehabilitation. The longitudinal deltoid
split is repaired with nonabsorbable sutures in a simple fashion, while reattachment to bone is often performed through
tunnels in the acromion. In a study by
DeOrio et al,18 prior deltoid detachment
or lateral acromionectomy was present in
approximately 48% of patients who presented for a second rotator cuff repair.
Consequently, postsurgery, it is important for patients to avoid activities that
82 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
J78B;
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Glenohumeral evaluation
No
Yes
Yes
Incision size
4-6 cm
3-4 cm
4-7 mm
Moderate to large
Small
Minimal
Repair techniques
Transosseus
Single-row,
transosseus
Single-row, double-row,
transosseus equivalent
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Postoperative pain
Moderate to
moderate-severe
Moderate
Mild
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rthroscopic treatment of rotator cuff tears has become a routine procedure as the trend toward
minimally invasive surgery continues.
Proponents of this technique point to the
lower risk of complications such as stiffness, infection, and deltoid avulsions.
However, critics emphasize the lack of
long-term outcome data, the controversy
over the optimal xation method, and the
technical difficulty associated with this
procedure. In contrast to the mini-open
repair technique, the all-arthroscopic cuff
repair requires only a small incision for
insertion of several cannulas up to 7 to
8 mm in diameter. The only insult to the
deltoid is the insertion of the cannula, as
no tissue retraction is required by this
technique (J78B;).
After identication of the appropriate landmarks, including the clavicle,
acromion, and spine of the scapula, all
arthroscopic portals are marked and a
1-cm longitudinal incision is made, as
described previously at the posterior
portal (<?=KH; )). An anterior working
portal is also established lateral to the
coracoid and a 5- to 6-mm cannula is
placed through this incision into the glenohumeral joint. Once the glenohumeral
joint has been examined arthroscopically,
a lateral working portal is established under direct visualization at the midline of
the lateral acromion. After the rotator cuff
tendon and footprint are prepared with
instrumentation from the lateral portal
(<?=KH; *), a superior-lateral accessory
portal can be made proximal and lateral
to the anterior working portal for anchor
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 83
CLINICAL COMMENTARY
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One of the essential goals following rotator cuff repair surgery is to educate
the patient regarding protection of the
repair site and the delayed nature of
the healing process. Soft tissue-to-bone
healing is slow and begins by formation
of brovascular tissue interface between
tendon and bone.62 It requires at least
12 weeks of healing to allow adequate
pull-out strength of the repair. 39 Factors
that improve tendon-to-bone healing are
84 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
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Rotator cuff repair surgery is functionally
debilitating for the patient. A multifaceted rehabilitation approach is critical to
regain ROM, strength, and endurance in
a timely and safe manner. The following
section will outline 12 factors that signicantly affect the postoperative rehabilitation program (7FF;D:?N7).
The rst factor to consider is the surgical approach. In particular, patients
who have deltoid muscle detachment
or release from the acromion, clavicle,
or both, as in a traditional open rotator
cuff repair, should not perform any active deltoid muscle contractions for 6 to
8 weeks. This is implemented to prevent
the avulsion of the deltoid muscle from
its insertion on the acromion. Conversely,
if a mini-open procedure is performed in
which the deltoid muscle is split vertically along the orientation of the deltoid
muscle bers, we will allow mild deltoid
isometric contractions in a controlled
fashion. Lastly, when an arthroscopic repair is performed, the surgery does not
involve the deltoid and there is signicantly less postoperative pain than following the mini-open or open rotator cuff
repair. Baker and Liu3 reported that 85%
of patients had good to excellent results,
and 88% of patients were satised with
the open rotator cuff repair. Most inter-
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 85
CLINICAL COMMENTARY
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Range of Motion One of the primary
86 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
SUMMARY
REFERENCES
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journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 87
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CLINICAL COMMENTARY
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org/10.2519/jospt.2004.0665
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WWW.JOSPT.ORG
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1. Surgical approach
Open and mini-open procedures
All-arthroscopic
2. Size of the tear
Small (1 cm)
Medium (1-3 cm)
Large (3-5 cm)
Massive (5cm)
Number of tendons involved
3. Tissue quality
Good
Adequate
Poor
4. Fixation method
Single-row
Double-row
Double-row (hybrid procedure)
Suture bridge
5. Location of tear
Supraspinatus
Infraspinatus/teres minor
Subscapularis
6. Type of tear
Crescent-shaped
U-shaped
L-shaped
Retracted
7. Mechanism of failure
Acute: traumatic single event
Biological: gradual wear
8. Timing of surgery
Immediate
Delayed
9. Rotator cuff tissue quality anterior and
posterior to the tear site
Good
Adequate
Poor
10.Patient characteristics
Smoking
Diabetes
General health
11. Access to care
Supervised
Independent home program
12. Physician philosophical approach
Conservative
Aggressive
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 89
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APPENDIX B
A1 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
Weeks 5-6
May use heat prior to exercises
Continue active assisted ROM and stretching exercises, especially for movements that
are not full
Shoulder exion
ER at 90 abduction
Initiate active ROM exercises
Shoulder exion scapular plane to 90 of exion
Shoulder abduction to 90 of abduction
Progress isotonic strengthening exercise program
ER tubing
Side-lying ER
Prone rowing at 45 of abduction
Prone horizontal abduction (bent elbow) at 90 of abduction
Biceps curls (isotonics) (very light resistance)
Phase III: Intermediate Phase (Weeks 7-14)
Goals:
Full active ROM (weeks 8-10)
Maintain full passive ROM
Dynamic shoulder stability
Gradual restoration of shoulder strength
Gradual return to functional activities
Week 7
Continue stretching and passive ROM (as needed to maintain full ROM)
Continue dynamic stabilization drills
Progress active ROM and light strengthening program
ER/IR tubing
ER side-lying
Lateral raises to 90 of abduction*
Full can in scapular plane to 90 of elevation*
Prone rowing
Prone horizontal abduction
Prone extension
Elbow exion
Elbow extension
* Patient must be able to elevate arm without shoulder or scapular hiking before initiating
isotonics; if unable, continue dynamic rhythmic stabilization glenohumeral joint
exercises
Week 8
Continue all exercise listed above
If physician permits, may initiate light functional activities
Week 10
Continue all exercise listed above
Progress to fundamental shoulder exercises (APPENDIX D)
Therapist may initiate isotonic resistance (0.5-kg weight) during exion and abduction*
* If nonpainful normal motion is exhibited and no substitution patterns
Weeks 11-14
Progress all exercises
Continue ROM and exibility exercises
Progress strengthening program (increase 0.5 kg/10 days if nonpainful)*
* Be sure when progressing patient no residual pain is present following exercises
Phase IV: Advanced Strengthening Phase (Weeks 15-24)
Goals:
Maintain full nonpainful ROM
Enhance functional use of upper extremity
Improve muscular strength and power
Gradual return to functional activities
Weeks 15-20
Continue ROM and stretching to maintain full ROM
Self-capsular stretches
Progress shoulder strengthening exercises
Fundamental shoulder exercises
Initiate interval golf program (if appropriate)61
Weeks 20-24
Continue all exercises listed above
Progress golf program to playing golf (if appropriate)
Initiate interval tennis program (if appropriate),61 week 24 (may wait until 6 mo to initiate,
physician will determine)
May initiate swimming, week 26
Phase V: Return to Activity Phase (Weeks 24-36)
Goals:
Gradual return to strenuous work activities
Gradual return to recreational sport activities
Maintain integrity of rotator cuff repair
Weeks 24-36
Continue fundamental shoulder exercise program (at least 4 times weekly)
Continue stretching, if motion is tight
Continue progression to sport and/or work activity/participation61
* Should continue fundamental shoulder exercise program until 12 mo following surgery
or until instructed to discontinue
Copyright 2004 by the Advanced Continuing Education Institute, LLC. All Rights Reserved. Any redistribution or reproduction of any materials herein is strictly prohibited.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | A2
CLINICAL COMMENTARY
APPENDIX C
A3 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
Copyright 2004 by the Advanced Continuing Education Institute, LLC. All Rights Reserved. Any redistribution or reproduction of any materials herein is strictly prohibited.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | A4
CLINICAL COMMENTARY
APPENDIX D
Illustration
1. L-Bar Flexion: Lie on back and grip L-Bar between index nger and thumb, elbows straight. Raise both arms
overhead as far as possible, keeping thumbs up. Hold for _____ seconds and repeat _____ times.
2. L-Bar External Rotation, Scapular Plane: Lie on back with involved arm 45 from body and elbow bent at 90.
Grip L-Bar in the hand of involved arm and keep elbow in exed position. Using uninvolved arm, push involved
arm into external rotation. Hold for _____ seconds, return to starting position. Repeat _____ times.
3. L-Bar Internal Rotation, Scapular Plane: Lie on back with involved arm 45 from body and elbow bent at 90.
Grip L-Bar in the hand of involved arm and keep elbow in exed position. Using the uninvolved arm, push involved
arm into internal rotation. Hold for _____ seconds, return to starting position. Repeat _____ times.
Strengthening Exercise
1. Tubing, External Rotation: Standing with involved elbow xed at side, elbow bent to 90 and involved arm across
the front of the body. Grip tubing handle while the other end of tubing is xed. Pull out with arm, keeping elbow at
side. Return tubing slowly and controlled. Perform _____ sets of _____ reps.
A5 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
Illustration
2. Tubing, Internal Rotation: Standing with elbow at side xed at 90 and shoulder rotated out. Grip tubing handle
while other end of tubing is xed. Pull arm across body keeping elbow at side. Return tubing slowly and
controlled. Perform _____ sets of _____ reps.
3. Lateral Raises to 90: Standing with arm at side, elbow straight, and palm against side. Raise arm to side,
rotating palm up as arm reaches 90. Do not go above shoulder height. Hold for _____ seconds and lower slowly.
Perform _____ sets of _____ reps.
4. Full Can: Stand with elbow extended and thumb up. Raise arm to shoulder level at 30 angle in front
of body. Do not go above shoulder level. Hold for _____ seconds and lower slowly. Perform _____ sets
of _____ reps.
5. Sidelying External Rotation: Lie on uninvolved side, with involved arm at side of body and elbow bent to
90. Keeping the elbow of involved arm xed to side, raise arm. Hold _____ seconds and lower slowly.
Perform _____ sets of _____ reps.
6. Prone Horizontal Abduction: Lie on table, face down, with involved arm hanging straight to oor and palm facing
down. Raise arm out to the side, parallel to the oor. Hold _____ seconds and lower slowly. Perform ______ sets
of ______ reps.
7. Prone Rowing: Lying on stomach with involved arm hanging over the side of the table, dumbbell in hand and
elbow straight. Slowly raise arm, bending elbow, and bring dumbbell as high as possible. Hold at the top for
_____ seconds, then lower slowly. Perform _____ sets of ______ reps.
Reproduced with permission from Wilk KE, Crockett HS, Andrews JR. Rehabilitation after rotator cuff repair surgery. Tech Shoulder Elbow Surg. 2000;1:128-144. Copyright 2004
by the Advanced Continuing Education Institute, LLC.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | A6