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To make sound clinical decisions when managing patients with shoulder disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting impairments, functional limitations, and possible disabilities. In this section, common pathologies and surgeries are presented and are related to corresponding preferred practice patterns (groupings of impairments) described in the Guide to Physical Therapist Practice2 (Table 17.2). Conservative and postoperative management of these conditions are described in this section.
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Joint Hypomobility: Nonoperative Management
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Restricted mobility of the glenohumeral joint may occur as a result of pathology, such as rheumatoid arthritis or osteoarthritis; from prolonged immobilization; or from unknown causes (idiopathic frozen shoulder). Associated impairments in muscle performance and connective tissue mobility may also be present in the cervical and shoulder girdle region.
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Related Pathologies and Etiology of Symptoms
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Rheumatoid arthritis and osteoarthritis. These disorders follow the clinical picture described in Chapter 11.
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Traumatic arthritis. This disorder occurs in response to a fall or blow to the shoulder or to microtrauma from faulty mechanics or overuse.
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Postimmobilization arthritis or stiff shoulder. This disorder occurs as a result of lack of movement or as a secondary effect from conditions such as heart disease, stroke, or diabetes mellitus.
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Idiopathic frozen shoulder. This disorder, which is also called adhesive capsulitis or periarthritis, is characterized by the development of dense adhesions, capsular thickening, and capsular restrictions, especially in the dependent folds of the capsule, rather than arthritic changes in the cartilage and bone, as seen with rheumatoid arthritis or osteoarthritis. The onset is insidious and usually occurs between the ages of 40 and 60 years; there is no known cause (primary frozen shoulder), although problems already mentioned in which there is a period of pain and/or restricted motion, such as with rheumatoid arthritis, osteoarthritis, trauma, or immobilization, may lead to a frozen shoulder (secondary frozen shoulder). With primary frozen shoulder, the pathogenesis may be a provoking chronic inflammation in musculotendinous or synovial tissue, such as the rotator cuff, biceps tendon, or joint capsule.45,74,104,145,148 Faulty posture and muscle strength imbalances may be consistent with this, predisposing the individual to impingement and overuse syndromes.1
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Clinical Signs and Symptoms
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Glenohumeral joint arthritis. The following characteristics are associated with the various types of glenohumeral (GH) joint arthritis that lead to hypomobility.
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Acute phase. Pain and muscle guarding limit motion, usually external rotation and abduction. Pain is frequently experienced radiating below the elbow and may disturb sleep. Owing to the depth of the capsule, joint swelling is not detected, although tenderness can be elicited by palpating in the fornix immediately below the edge of the acromion process between the attachments of the posterior and middle deltoid.
Subacute phase. Capsular tightness begins to develop. Limited motion is detected, consistent with a capsular pattern (external rotation and abduction are most limited, and internal rotation and flexion are least limited). Often, the patient feels pain as the end of the limited range is reached. Joint-play testing reveals limited joint play. If the patient can be treated as the acute condition begins to subside by gradually increasing shoulder motion and activity, the complication of joint and soft tissue contractures can usually be minimized.139,145
Chronic phase. Progressive restriction of the GH joint capsule magnifies the signs of limited motion in a capsular pattern and decreased joint play. There is significant loss of function with an inability to reach overhead, outward, or behind the back. Aching is usually localized to the deltoid region.
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Idiopathic frozen shoulder. This clinical entity progresses through a series of four stages following a classic continuum.*
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Stage 1. Characterized by a gradual onset of pain that increases with movement and is present at night. Loss of external rotation motion with intact rotator cuff strength is common. The duration of this stage is usually less than 3 months.
Stage 2 (Often referred to as the "Freezing" Stage). Characterized by persistent and more intense pain even at rest. Motion is limited in all directions and cannot be fully restored with an intra-articular injection. This stage is typically between 3 and 9 months.
Stage 3 ("Frozen" Stage). Characterized by pain only with movement, significant adhesions, and limited GH motions, with substitute motions in the scapula. Atrophy of the deltoid, rotator cuff, biceps, and triceps brachii muscles may be noted. This stage is between 9 and 15 months.
Stage 4 ("Thawing" Stage). Characterized by minimal pain and no synovitis but significant capsular restrictions from adhesions. Motion may gradually improve during this stage. This stage lasts from 15 to 24 months or longer. Some patients never regain normal ROM.
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Some references indicate that spontaneous recovery occurs, on average, 2 years from onset,74 although others have reported long-term limitations without spontaneous recovery.177 Inappropriately aggressive therapy at the wrong time may prolong the symptoms.16 Management guidelines are progressed based on the continuum of stages104 and are the same as for acute (maximum protection during stages 1 and 2), subacute (controlled motion during stage 3), and chronic (return to function during stage 4) joint pathology described in this section.
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Common Structural and Functional Impairments
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Night pain and disturbed sleep during acute flares
Pain on motion and often at rest during acute flares
Mobility: decreased joint play and ROM, usually limiting external rotation and abduction with some limitation of internal rotation and elevation in flexion
Posture: possible faulty postural compensations with protracted and anteriorly tilted scapula, rounded shoulders, and elevated and protected shoulder
Decreased arm swing during gait
Muscle performance: general muscle weakness and poor endurance in the glenohumeral muscles with overuse of the scapular muscles leading to pain in the trapezius, levator scapulae, and posterior cervical muscles
Substitution for limited glenohumeral motion with increased scapular motion, especially elevation.
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Common Activity Limitations and Participation Restrictions (Functional Limitations and Disabilities)
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Inability to reach overhead, behind head, out to the side, and behind back; thus, having difficulty dressing (putting on a jacket or coat or in the case of women, fastening undergarments behind their back), reaching hand into back pocket of pants (to retrieve wallet), reaching out a car window (to use an ATM machine), self-grooming (combing hair, brushing teeth, washing face), and bringing eating utensils to the mouth
Difficulty lifting weighted objects, such as dishes into a cupboard
Limited ability to sustain repetitive activities
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Glenohumeral Joint Hypomobility: Management—Protection Phase
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See 'General Guidelines for Management When Symptoms are Acute' in Chapter 10 and Box 10.1.
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Control Pain, Edema, and Muscle Guarding
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The joint may be immobilized in a sling to provide rest and minimize pain.
Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation techniques are initiated as soon as the patient tolerates movement in order to minimize adhesion formation.
Gentle soft tissue mobilization to the cervical and periscapular muscles may improve patient comfort and minimize guarding, as may cervical range of motion and/or cervical grade I or II passive intervertebral mobilizations/manipulations.
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Maintain Soft Tissue and Joint Integrity and Mobility
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PRECAUTION: If there is increased pain or irritability in the joint after use of the following techniques, either the dosage was too strong or the techniques should be modified by decreasing the range of passive movement or delaying joint glides.
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CONTRAINDICATION: If there are mechanical restrictions causing limited motion, appropriate tissue stretching should be initiated only after the inflammation subsides.
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Passive range of motion (PROM) in all ranges of pain-free motion (see Chapter 3). As pain decreases, the patient is progressed to active ROM with or without assistance, using activities such as rolling a small ball or sliding a rag on a smooth table top in flexion, abduction, and circular motions. Be sure the patient is taught proper mechanics and avoids faulty patterns, such as scapular elevation or a slumped posture.
Passive joint distraction and glides, grade I and II with the joint placed in a pain-free position (see Chapter 5).
Pendulum (Codman's) exercises are techniques that use the effects of gravity to distract the humerus from the glenoid fossa.33,36 They help relieve pain through gentle traction and oscillating movements (grade II) and provide early motion of joint structures and synovial fluid. No weight is used during this phase of treatment (see Fig. 17.22).
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CLINICAL TIP
Many patients perform pendulum exercises incorrectly by utilizing the GH muscles and performing large motions; the technique must be taught as small, gentle pendular motions initiated with body swaying.116
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Gentle muscle setting to all muscle groups of the shoulder and adjacent regions, including cervical and elbow muscles because of their close association with the shoulder girdle. Instructions are given to the patient to gently contract a group of muscles while slight manual resistance is applied—just enough to stimulate a muscle contraction without provoking pain. The emphasis is on rhythmic contracting and relaxing of the muscles to help stimulate blood flow and prevent circulatory stasis.
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Maintain Integrity and Function of Associated Regions
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Complex regional pain syndrome type I (reflex sympathetic dystrophy) is a potential complication after shoulder injury or immobility. Therefore, additional exercises, such as having the patient repetitively squeeze a ball or other soft object, may be given for the hand.
The patient is educated on the importance of keeping the joints distal to the shoulder complex as active and mobile as possible. The patient or family member is taught to perform ROM exercises of the elbow, forearm, wrist, and fingers several times each day while the shoulder is immobilized. If tolerated, active or gentle resistive ROM is preferred to passive ROM for a greater effect on circulation and muscle integrity.
If edema is noted in the hand, instruct the patient to elevate the hand above the level of the heart whenever possible.
Cervical ROM (active and/or passive), intervertebral joint mobilizations, and soft tissue mobilization should also be considered.
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CLINICAL TIP
For conditions in which there is potentially a prolonged acute/inflammatory stage, such as with rheumatoid arthritis and during Stages I or II of idiopathic frozen shoulder, it is critical to teach the patient active-assistive exercises to maintain muscle and joint integrity and as much mobility as possible without exacerbating the symptoms.
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GH Joint Hypomobility: Management—Controlled Motion Phase
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When symptoms are subacute, follow the guidelines as described in Chapter 10, Box 10.2, emphasizing joint mobility, neuromuscular control, and instructions to the patient for self-care.
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Control Pain, Edema, and Joint Effusion
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Functional activities. It is important to carefully monitor activities. If the joint is immobilized, the amount of time the shoulder is free to move each day is progressively increased.
Range of motion. ROM for glenohumeral and scapula motions is progressed up to the point of pain. The patient is instructed in the use of self-assistive ROM techniques, such as the wand exercises or hand slides on a table.
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PRECAUTION: With increased pain or decreased motion after these techniques, the activity may be too intense or the patient may be using faulty mechanics. Reassess the technique and modify it by restricting the joint to a safer range of motion, correcting faulty movements, or altering the intensity, frequency, and/or duration of the technique.
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Progressively Increase Joint and Soft Tissue Mobility
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Passive joint mobilization techniques. Grade III sustained or grade III and IV oscillations that focus on the restricted capsular tissue at the end of the available ROM are used to increase joint capsule mobility100,150,211 (see Box 17.1 and Figs. 5.15 through 5.20 in Chapter 5). End-of-range techniques include rotating the humerus and then applying either a grade III distraction or a grade III glide to stretch the restrictive capsular tissue or adhesions (see Figs. 5.17, 5.21, and 17.20).
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Use a grade I distraction with all gliding techniques. If the joint is highly irritable and gliding in the direction of restriction is not tolerated, glide in the opposite direction. As pain and irritability decrease, begin to glide in the direction of restriction.100
++
FOCUS ON EVIDENCE
Evidence supporting joint mobilization techniques is limited. A multiple-subject case study, using seven subjects with adhesive capsulitis of the glenohumeral joint (mean disease duration 8.4 months, range 3 to 12 months) treated with end-range mobilization techniques twice a week for 3 months, showed increased active and passive range and increased capacity of the joint capsule at the end of treatment and at the 9-month follow-up. No control groups were used; therefore, the natural course of the disease could not be excluded as the explanation for improvement.211
A follow-up study by the same author randomly assigned 100 subjects with stage II adhesive capsulitis to a group receiving high-grade mobilization techniques (end-range stretching using Maitland grade III or IV) or a group receiving low-grade mobilization techniques (Maitland grade I or II in nonstressful positions). After 3 months of treatment, both groups exhibited clinically significant improvement, with the group receiving the high-grade mobilization techniques showing greater improvement than the low-grade mobilization group. Because there was no control group, natural progression could not be ruled out.212
A study exploring the effect of the direction of joint mobilization demonstrated that a posterior glide was more effective than an anterior glide to increase glenohumeral external rotation range of motion. Patients with stage II to IV primary adhesive capsulitis received distraction plus grade III sustained mobilizations, held for at least 1 minute, with treatment duration of 15 minutes, for 6 treatment sessions. Anterior mobilizations were progressed by placing the humerus at end-range abduction and external rotation, while posterior mobilizations were progressed by placing the humerus at end-range flexion and external rotation. At the end of the sixth visit, subjects in the anterior mobilization group (n = 10) had an increase in external rotation ROM of 3.0°, while those in the posterior mobilization group (n = 8) had an increase of 31.3°, a difference that was statistically significant.99
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PRECAUTION: Carefully monitor the joint reaction to the mobilization stretches; if irritability increases, grade III or IV techniques should not be undertaken until the chronic stage of healing.
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Self-mobilization techniques. The following self-mobilization techniques may be used for a home program.
Caudal glide. Patient position and procedure: Sitting on a firm surface and grasping the fingers under the edge. The patient then leans the trunk away from the stabilized arm (Fig. 17.8).
Anterior glide. Patient position and procedure: Sitting with both arms behind the body or lying supine supported on a solid surface. The patient then leans the body weight between the arms (Fig. 17.9).
Posterior glide. Patient position and procedure: Prone, propped up on both elbows. The body weight shifts downward between the arms (Fig. 17.10).
Manual stretching. Manual stretching techniques are used to increase mobility in shortened muscles and related connective tissue.
Self-stretching exercises. As the joint reaction becomes predictable and the patient begins to tolerate stretching, self-stretching techniques are taught (see Figs. 17.24,17.25,17.26,17.27,17.28,17.29 in the exercise section).
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Inhibit Muscle Spasm and Correct Faulty Mechanics
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Muscle spasm may lead to a faulty deltoid-rotator cuff mechanism and scapulohumeral rhythm when the patient attempts arm elevation (Fig. 17.11). The head of the humerus may be positioned cranially in the joint, making it difficult and/or painful to elevate the arm because the greater tuberosity impinges on the coracoacromial arch. In this case, repositioning the head of the humerus with a caudal glide is necessary before proceeding with any other form of shoulder exercise. The patient also needs to learn to avoid "hiking the shoulder" when at rest or when elevating the arm. The following techniques may address these problems and faulty mechanics. See also 'Mobilization with Movement Techniques' in the next section.
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++
Gentle joint oscillation techniques to help decrease the muscle spasm (grade I or II).
Sustained caudal glide joint techniques to reposition the humeral head in the glenoid fossa.
Protected weight bearing, such as leaning hands against a wall or on a table, stimulates co-contraction of the rotator cuff and scapular stabilizing muscles and improves synovial fluid movement through hyaline cartilage compression. Techniques are progressed by gentle rocking forward/backward and side-to-side, moving from bilateral to unilateral, increasing the angle of the joint, or adding perturbations.
GH internal/external rotation strengthening to facilitate stabilization of the humeral head (see Fig. 17.52).
Movement retraining to minimize the substitution pattern of scapular elevation can be initiated by providing the visual feedback of a mirror or the tactile feedback of the opposite hand placed on the ipsilateral upper trapezius.
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Improve Joint Tracking
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Mobilization with movement (MWM) techniques may assist with retraining muscle function for proper tracking of the humeral head.137
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Shoulder MWM for painful restriction of shoulder external rotation (Fig. 17.12).
Patient position: Supine lying with folded towel under the scapula; the elbow is near the side and flexed to 90°. A cane is held in both hands.
Therapist position and procedure: Stand on the opposite side of the bed facing the patient and reach across the patient's torso to cup the anteromedial aspect of the head of the humerus with reinforced hands. Apply a pain-free graded posterolateral glide of the humeral head on the glenoid. Instruct the patient to use the cane to push the affected arm into the previously restricted range of external rotation. Sustain the movement for 10 seconds and repeat in sets of 5 to 10. It is important to maintain the elbow near the side of the trunk and ensure that no pain is experienced during the procedure. Adjust the grade and direction of the glide as needed to achieve pain-free function.
Shoulder MWM for painful restriction of internal rotation and inability to reach the hand behind the back (Fig. 17.13).
Patient position: Standing with a towel draped over the unaffected upper trapezius and affected hand at current range of maximum pain-free position behind back. The patient's hand on the affected side grasps the towel behind the back.
Therapist position and procedure: Stand facing the patient's affected side. Place the hand closest to the patient's back high up in the axilla with the palm facing outward to stabilize the scapula with an upward and inward pressure. With the hand closest to the patient's abdomen, hook the thumb in the cubital fossa and grasp the lower humerus to provide an inferior glide. Your abdomen is in contact with the patient's elbow to provide an adduction force to the arm. Have the patient pull on the towel with the unaffected hand to draw the affected hand up the back while the mobilization force is being applied in an inferior direction. Ensure that no pain is experienced during the procedure. Adjust the grade and direction of glide as needed to achieve pain-free function. Maximal glide should be applied to achieve end-range loading.
Shoulder MWM for painful arc or impingement signs. If impingement signs are present in addition to the capsular restrictions, the MWM active elevation technique may be appropriate. (See Fig. 17.17 and description in the impingement section.)
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Improve Muscle Performance
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Faulty postures or shoulder girdle mechanics, such as scapula elevation or protraction or excessive trunk movement, displayed when moving the upper extremity in various functional patterns should first be identified and corrected. Manual techniques, stretches, and strengthening exercises are initiated to correct muscle length or strength imbalances, followed by an emphasis on developing active control of weak musculature. As the patient learns to activate the weak muscles, progress to strengthening in functional patterns.
Because faulty postures or shoulder girdle mechanics may be impacted by impaired trunk strength or control, an emphasis on trunk stability should also be considered. Exercises to manage faulty spinal posture are described in Chapter 16, with active cervical retraction and thoracic extension especially important for shoulder function.
After proper mechanics are restored, the patient should perform active ROM of all shoulder motions daily and return to functional activities to the extent tolerated.
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GH Joint Hypomobility: Management—Return to Function Phase
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For joint impairments in the chronic stage, follow the guidelines described in Chapter 10, Box 10.4.
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Progressively Increase Flexibility and Strength
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Stretching and strengthening exercises are progressed as the joint tissue tolerates. The patient should be actively involved in self-stretching and strengthening by this time, so emphasis during treatment is on maintaining correct mechanics, safe progressions, and exercise strategies for return to function. Progressions may include increasing resistance and repetitions, performing exercises through multiple planes, adding perturbations, and incorporating regional muscle groups (such as the trunk) into dynamic exercises.
If capsular tissue is still restricting ROM, vigorous manual stretching and joint mobilization techniques are applied.
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Prepare for Functional Demands
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If the patient is involved in repetitive heavy lifting, pushing, pulling, carrying, or reaching, exercises are progressed to replicate these demands. See the last section of this chapter and Chapter 23 for suggestions.
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GH Joint Management: Postmanipulation Under Anesthesia
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Occasionally, no progress is made, and the physician chooses to perform manipulation under anesthesia. Following this procedure, there is an inflammatory reaction and the joint is treated as an acute lesion. If possible, joint mobility and passive ROM techniques are initiated while the patient is still in the recovery room. Surgical intervention with incision of the dependent capsular fold may be used if the adhesions are not broken with the manipulation.
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Postoperative treatment is the same with the following considerations.148
++
The arm is kept elevated overhead in abduction and external rotation during the inflammatory reaction stage; treatment principles progress as with any joint lesion.
Therapeutic exercises are initiated the same day while the patient is still in the recovery room, with emphasis on internal and external rotation in the 90° (or higher) abducted position.
Joint mobilization procedures are used, particularly a caudal glide, to prevent readherence of the inferior capsular fold.
When sleeping, the patient may be required to position the arm in abduction for up to 3 weeks after manipulation.
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Acromioclavicular and Sternoclavicular Joints
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Related Pathologies and Etiology of Symptoms
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Overuse syndromes. Overuse syndromes of the AC joint may be from repeated stressful movement of the joint with the arm at waist level, such as with grinding, packing assembly, and construction work,75 or repeated diagonal extension, adduction, and internal rotation motions, as when spiking a volleyball or serving in tennis. The AC joint is susceptible to overuse syndromes in conjunction with arthritis or following a traumatic injury.
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Subluxation or dislocation. Subluxation or dislocation of either joint usually is caused by falling against the shoulder or against an outstretched arm. At the AC joint, the distal end of the clavicle often displaces posteriorly and superiorly on the acromion, and the ligaments supporting the AC joint may rupture.147 Clavicular fractures may also result from a fall or other high force events such as a motor vehicle accident.147 After trauma and associated overstretching of the capsules and ligaments of either joint, hypermobility is usually permanent because there are almost no muscles that provide direct stability to these joints.
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Hypomobility. Decreased clavicular mobility may occur with SC joint osteoarthritis and may contribute to a thoracic outlet syndrome (TOS) with a compromise of space for the neuromuscular bundle as it courses between the clavicle and first rib (described in Chapter 13).
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Common Structural and Functional Impairments
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Pain localized to the involved joint or ligament.
Painful arc toward the end-range of shoulder elevation.
Pain with shoulder horizontal adduction or abduction.
Hypermobility in the joints if trauma or overuse is involved.
Hypomobility in the joints if sustained posture, arthritis, or immobility is involved.
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Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
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Limited ability to sustain repeated forceful movements of the arm, such as with grinding, packing, assembly, and construction work.75
Inability to reach overhead or perform repetitive overhead activities without pain.
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Nonoperative Management of AC or SC Joint Strain or Hypermobility
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Minimize joint loading by supporting the weight of the arm with a sling.
Cross-fiber massage to the capsule or ligaments.
Maintain ROM of the glenohumeral joint and scapulothoracic articulation.
Instruction in self-application of cross-fiber massage if joint symptoms occur after excessive activity.
Increase strength of shoulder complex, trunk, and legs.
Gradually return to functional activities
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Nonoperative Management of AC or SC Joint Hypomobility
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Joint mobilization techniques are used to increase joint mobility (see Figs. 5.22 through 5.24).
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Glenohumeral Joint Surgery and Postoperative Management
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Severe deterioration of one or both surfaces of the GH joint or an acute or nonunion fracture of the proximal humerus often must be managed with surgical intervention. Underlying pathologies that cause advanced joint destruction include late-stage osteoarthritis (OA), rheumatoid arthritis (RA), traumatic arthritis, cuff tear arthropathy, and osteonecrosis (avascular necrosis) of the head of the humerus as the result of a fracture of the anatomical neck of the humerus or long-term use of steroids for systemic disease.
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The most common surgical procedure used to treat advanced shoulder joint pathology is glenohumeral arthroplasty, often simply referred to as shoulder arthroplasty.38 In rare situations, arthrodesis (surgical ankylosis) of the GH joint may have to be selected as an alternative to arthroplasty or as a salvage procedure.126
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The goals of these surgical procedures and the postoperative rehabilitation program are to: (1) relieve pain, (2) improve shoulder mobility or stability, and (3) restore or improve strength and functional use of the upper extremity. The extent to which these goals are achieved is predicated on the patient's participation in postoperative rehabilitation; the distinguishing features and severity of the underlying pathology; the prosthetic design and surgical techniques; the integrity of the rotator cuff mechanism and other soft tissues; and the age, overall health, and anticipated activity level of the patient.38,126,182,189
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Glenohumeral Arthroplasty
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Arthroplasty of the GH joint falls into several categories, the most common of which are total shoulder arthroplasty (TSA),126,141,182,189 in which the glenoid and humeral surfaces are replaced (Fig. 17.14), and hemireplacement arthroplasty (hemiarthroplasty), in which one surface, the humeral head, is replaced.6,63,126,143,182,239 Reverse total shoulder arthroplasty (rTSA) is another type of arthroplasty, typically used when the rotator cuff integrity is compromised.42,129,216 Other categories of shoulder arthroplasty include interpositional and resurfacing arthroplasties, which involve less extensive removal of bone.126,182,189,206
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Indications for Surgery
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The following structural and functional impairments associated with these pathologies are widely accepted indications for GH arthroplasty.*
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The primary indication is persistent and incapacitating pain (at rest or with activity) secondary to GH joint destruction.
Secondary indications include loss of shoulder mobility or stability and/or upper extremity strength leading to inability to perform functional tasks with the involved upper extremity.
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Implant design, materials, and fixation. Since the pioneering work of Neer during the 1960s and 1970s141,143 and many other investigators,29 prosthetic designs and surgical techniques for replacing the shoulder joint have continued to evolve. The designs of current-day TSA hardware, composed of a high-density polyethylene glenoid component (usually all plastic) and a modular inert metal humeral component, closely approximate the biomechanical characteristics of the human shoulder.232 The exception to this is the rTSA, the design of which reverses the ball and socket location of the native shoulder. Specifically, the glenoid fossa is replaced with a convex, "glenospherical" component attached to a glenoid base and the humeral head with a stemmed cup.213 Fixation of the prosthetic components is achieved with a press fit, bioingrowth, or cement. The type of fixation selected by the surgeon depends on the component (glenoid or humeral), the underlying pathology, and the quality of the bone stock. Cement fixation is most often necessary in patients with osteoporosis.*
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The designs of total shoulder replacements, ranging from unconstrained to semiconstrained to constrained, provide varying amounts of mobility and stability to the GH joint. Box 17.3 summarizes the characteristics of each of these designs.38,125,126,180,182,189,206
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BOX 17.3 Designs of Prosthetic Implants for Total Shoulder Arthroplasty Unconstrained
Anatomical design with a small, shallow glenoid component combined with a stemmed humeral component
The most frequently used prosthetic design
Provides the greatest freedom of shoulder motion but no inherent stability
Indicated when the rotator cuff mechanism is intact or can be repaired to provide dynamic stability to the GH joint
Semiconstrained A larger glenoid component that is hooded or cup-shaped
Some degree of joint stability inherent in the design
Indicated when erosion of the glenoid fossa can be compensated for by reaming the fossa and rotator cuff function; although deficient preoperatively, can be improved by repair
Reversed Ball and Socket Small humeral socket that slides on a larger ball-shaped glenoid component
Couples some degree of stability with mobility for rotator cuff-deficient shoulders that cannot be repaired
Provides an alternative to standard, semiconstrained total shoulder arthroplasty (TSA) and hemiarthroplasty
Constrained Fixed fulcrum, ball-in-socket designs with congruency of the glenoid and humeral components
Greatest amount of inherent joint stability but less mobility than less constrained designs
Once thought to be an alternative to hemiarthroplasty for the selected patient with a deficient rotator cuff or cuff tear arthropathy or chronic/recurrent GH joint dislocation after a previous TSR
Rarely used today owing to high rate of loosening or failure of the components
+
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NOTE: The description of constrained designs is included in Box 17.3 for historical purposes and for a comparison with less constrained designs. Because of the high rate of complications that occurs with constrained designs, these implant systems are rarely, if ever, used today.38,126
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Selection of procedure. Controversy exists over the specific criteria for selection of TSA versus rTSA versus hemiarthroplasty, but in general, it depends on the etiology and severity of the joint deterioration and the condition of the periarticular soft tissues, particularly the rotator cuff mechanism.126,190 Several examples that follow underscore the complexity of the clinical decision-making process involved in the choice of operative procedure and prosthetic design.
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In patients with late-stage primary OA, the GH joint typically exhibits loss or thinning of the articular cartilage of the head of the humerus and the posterior portion of the glenoid fossa. The rotator cuff is intact in approximately 90% to 95% of these patients, making them good candidates for either TSA or hemiarthroplasty.38,125,161,180,182,189 However, opinions vary on whether selection of an unconstrained TSA yields results that are better than or equal to those of hemiarthroplasty for shoulders with these characteristics.38,126,157,182,192
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Chronic synovitis, associated with RA and other types of synovium-based arthritis, tends to erode periarticular soft tissues in addition to the articular surfaces of a joint. As a consequence, a full-thickness tear of a rotator cuff tendon (typically the supraspinatus) develops in 25% to 40% of these patients and a rupture of the biceps tendon in an even greater percentage.63,180,189,197,206 If the soft tissues can be repaired and their functions improved, a semiconstrained TSA that may include bone grafting at the glenoid to improve prosthetic fixation may be indicated. If an effective cuff repair cannot be achieved, an rTSA is usually indicated. When there is insufficient bone stock for fixation of a glenoid implant, hemiarthroplasty is usually the procedure of choice.63,126,180,182,190,197,206
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Hemiarthroplasty is often used when the articular surface and underlying bone of the humeral head have deteriorated, but the glenoid fossa is reasonably intact, as seen with osteonecrosis of the head of the humerus.38,126,189 A patient with severe, chronic pain and loss of function as the result of a massive, irreparable cuff tear and subsequent development of a cuff tear arthropathy typically is a candidate for rTSA. (First used by Neer, the term "cuff tear arthropathy" refers to deterioration and eventual collapse of the head of the humerus, an infrequent but debilitating long-term result of a primary, massive, and irreparable tear of the rotator cuff.)126,180,221,239
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Chronic deficiency of the rotator cuff mechanism leads to superior migration of the head of the humerus in the glenoid fossa. If a glenoid component is inserted under these conditions, the superior migration creates an incongruous articulation that accentuates the risk of loosening and premature wear of the glenoid implant.37,82,180 The rTSA was developed to overcome this complication by eliminating translation between the glenosphere and humeral articular surface. Other features of the rTSA include reduced forces on the glenoid component, inherent stability owing to the congruency of the components, and increased deltoid moment arms. One limitation of the rTSA design is a decrease in glenohumeral range of motion.23,129,213
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TSA, rTSA, and hemiarthroplasty are open surgical procedures performed with the patient in a semi-reclining position. These operative procedures involve the following components*: (1) anterior approach using a deltopectoral incision that extends from the AC joint to the deltoid insertion for adequate surgical exposure; (2) release (tenotomy) of the subscapularis tendon from its proximal attachment on the lesser tuberosity; (3) anterior capsulotomy; (4) exposure of the humeral head for a humeral osteotomy; and (5) preparation of the humeral canal for insertion of the prosthetic implant. The glenoid fossa is débrided and for a TSA is precisely contoured, so the glenoid implant can be placed flush within the fossa. The subscapularis is then reattached and may be lengthened (medial advancement or Z-plasty) if external rotation is limited.
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Reconstruction and balancing of soft tissues is critical for optimal function after TSA, rTSA, and hemiarthroplasty. "Balancing" refers to the intraoperative lengthening or tightening of soft tissues to restore as near-normal resting tension in the tissues as possible, particularly in the rotator cuff, biceps, and deltoid muscle-tendon units.
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Concomitant procedures that may be necessary during shoulder arthroplasty include:
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Repair of a deficient rotator cuff if the quality of the cuff tissue is sufficient.
Capsular plication and tightening for chronic subluxation or dislocation (usually posterior) of the GH joint.
Anterior acromioplasty for a history of impingement syndrome.
Bone graft of the glenoid if bone stock is insufficient for fixation of the glenoid implant.
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After implantation of the prosthetic component(s) and repair of soft tissues but before closure of the skin incision, the shoulder is passively moved through all planes of motion to visually evaluate the stability of the prosthetic joint and the integrity of the repaired soft tissues. This determines the anatomical ROM possible after surgery and how aggressive the postoperative program can be.38,126
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Although the incidence of intraoperative and postoperative complications after current-day arthroplasty is low, even a single complication can adversely affect the functional outcome. The incidence of complications after TSA tends to be higher in patients with a deficient rotator cuff mechanism, osteoporosis, and a preoperative history of chronic GH joint instability.81 Aside from medical complications, such as infection or a deep vein thrombosis, complications specific to shoulder arthroplasty are noted in Box 17.4.37,81
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BOX 17.4 Complications Specific to Glenohumeral Arthroplasty Intraoperative Complications
Insufficient lengthening of a tight subscapularis muscle-tendon unit
Intraoperative damage to the axillary or suprascapular nerves, affecting the deltoid and supraspinatus/infraspinatus muscles, respectively
Fracture of the humerus
Soft Tissue-Related Postoperative Complications Re-tearing a repaired rotator cuff mechanism
Postoperative disruption of the repaired subscapularis
Chronic instability or dislocation of the GH joint
Incidence of dislocation is higher after rTSA than TSA
Progressive erosion of the articular surface of the glenoid fossa (after hemiarthroplasty)
Implant-Related Postoperative Complications After TSA mechanical (aseptic) loosening, premature wear, or fracture of the polyethylene glenoid implant
Most often seen in a rotator cuff-deficient shoulder
Due to excessive stresses at the bone–prosthesis interface
Low incidence with unconstrained designs but higher with early-generation constrained designs
Loosening of the humeral prosthesis after hemiarthroplasy
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Postoperative Management
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NOTE: Effective patient education and close communication among the therapist, surgeon, and patient are the basis of an effective and safe rehabilitation program. Postoperative management is individualized to address the specific surgical procedures used and to meet the unique needs of each patient.
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Special Considerations
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Integrity of the rotator cuff. Regardless of the underlying cause of late-stage glenohumeral arthritis, the goals, components, and rate of progression of a rehabilitation program after TSA or hemiarthroplasty are influenced by the pre- and postoperative integrity of the rotator cuff mechanism. The rehabilitation program for a patient with an intact rotator cuff prior to shoulder arthroplasty can be progressed more rapidly than the program for a patient with coexisting rotator cuff deficiency requiring a concomitant cuff-tendon repair at the time of shoulder arthroplasty.
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If the rotator cuff was intact prior to surgery, the emphasis of postoperative rehabilitation is to restore shoulder mobility and functional use of the arm as soon as possible while protecting soft tissues as they heal. In contrast, with a tenuous repair, or a preoperative history of recurrent GH dislocation, rehabilitation must place greater emphasis on improving or maintaining joint stability for functional use of the arm than on increasing shoulder mobility.47,52,57,103,126
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Intraoperative ROM. Goals for safe, stable postoperative ROM are based on intraoperative ROM measurements taken prior to closing the surgical incision. For a patient with an unconstrained TSA and sufficient postoperative shoulder stability (static and dynamic), the goal at the conclusion of rehabilitation is to achieve active ROM equal to intraoperative ROM—ideally, 140° to 150° of shoulder elevation and 45° to 50° of external rotation.47,126 For a patient with more constrained TSA, a deficient rotator cuff mechanism, or capsuloligamentous laxity, intraoperative ROM is typically less, and postoperative goals focus more on developing dynamic stability and less on shoulder mobility. Following rTSA, ROM is limited to 0° to 20° external rotation and 90° to 120° elevation for 3 months.23,129
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Posture. If the postural changes associated with aging108 (increased thoracic kyphosis and scapular protraction) are present, it is important to emphasize an erect sitting or standing posture during elevation of the arm and to incorporate spinal extension and scapular retraction exercises into the postoperative program.
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Immobilization and Postoperative Positioning
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At the close of the surgical procedure, the operated arm is placed in some type of shoulder immobilizer, usually a sling or sometimes a splint, to protect reattached and repaired soft tissues and for comfort.6,38,126,180,189,208 Early postoperative positioning that protects the operated shoulder is detailed in Box 17.5.
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BOX 17.5 Positioning After Shoulder Arthroplasty: Early Postoperative (Maximum Protection) Phase Supine
Sitting With Tenuous Rotator Cuff Repair
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Initially, the sling or splint is removed only for exercise and bathing. A patient who did not require repair of the rotator cuff is weaned from the sling during the day as quickly as possible to prevent postoperative stiffness. However, a patient who has undergone a cuff repair or other soft tissue reconstruction may need to wear a sling or splint while out in crowded areas or during sleep for approximately 4 to 6 weeks to protect the repaired tissues until sufficient healing has occurred.24,27,38,47,52,53,103,126,198
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A patient who has undergone rTSA wears a shoulder immobilizer (sling and swathe) continuously for at least 3 to 4 weeks following surgery except for daily personal hygiene and periodic PROM (pendulum exercises) during the day.129
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The guidelines for progression of exercises during each phase of rehabilitation after TSA, rTSA, or hemiarthroplasty presented in this section are drawn from the limited number of published protocols available, all of which are based on clinical experience rather than evidence from controlled studies and none of which has been shown to be more effective than another.* Almost all of these protocols are time-based, with few criteria reported for advancing a patient from one phase of rehabilitation to the next.
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Recently, however, several resources have suggested such criteria.23,39,52,213,221 It is important to note that these criteria and suggested timelines for progression of exercises and functional activities must be adapted to each patient based on periodic evaluations of the patient's status and ongoing communication between the therapist and the surgeon.
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NOTE: The exercise guidelines in this section are for patients without preoperative rotator cuff deficiency and who did not undergo a cuff repair during TSA or hemiarthroplasty. For patients with a poor quality rotator cuff mechanism or who underwent rTSA, modifications in guidelines are noted. A comparison of postoperative exercise guidelines and precautions following TSA versus rTSA are summarized in Table 17.3.
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CLINICAL TIP
Remember, regardless of implant design, pain relief is the primary goal of shoulder arthroplasty, with improvement in functional mobility a secondary goal. Although improvements in surgical techniques and implant technology now allow more accelerated progression of postoperative rehabilitation than several decades ago, it is still important to proceed judiciously during each phase of rehabilitation to avoid damage to the healing soft tissues, implant loosening, or excessive muscle fatigue or irritation.
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Exercise: Maximum Protection Phase
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The maximum protection phase of rehabilitation following TSA begins on the first postoperative day and extends for 4 to 6 weeks. The emphasis of this first phase is patient education, pain control, and initiation of ROM exercises to prevent adhesions and restore shoulder mobility as early as possible to the ranges achieved during surgery. Early motion is permissible after uncemented and cemented shoulder arthroplasty.
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While the patient is hospitalized (usually for 3 to 4 days after surgery), patient education includes reviewing early postoperative precautions and teaching the initial exercises in the patient's home program. Precautions during the first 4 to 6 weeks after TSA, when protection of soft tissues is crucial, are summarized in Box 17.6. A patient's adherence to these precautions is of the utmost importance during this phase of rehabilitation.
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BOX 17.6 Precautions for the Maximum Protection Phase of Rehabilitation Following Shoulder Arthroplasty Exercise
Short but frequent exercise sessions (four or five times per day).
Low number of repetitions per exercise.
Only passive or assisted shoulder ROM exercises and only within the "safe" limits of ranges noted during surgery. Absolutely no end-range stretching.
Passive external rotation to neutral after rTSA or to less than 30° after TSA to avoid excessive stress to the surgically repaired subscapularis muscle.
During passive or assisted shoulder rotation with the patient lying supine, position the humerus slightly anterior to the midline of the body (by placing the arm on a folded towel) to avoid excessive stress to the anterior capsule and suture line.
No hyperextension or horizontal abduction (beyond neutral) of the shoulder to avoid stress to the anterior capsule.
No combined extension, adduction, and internal rotation
If an overhead rope-pulley system is used for assisted elevation of the arm, initially have the patient face the doorway and pulley apparatus, so shoulder elevation occurs only within a limited range.
Maintain an erect trunk during passive or assisted elevation of the arm while sitting or standing to avoid subacromial impingement of soft tissues.
In most instances, no active (unassisted), antigravity, dynamic shoulder exercises, particularly resisted internal rotation.
No resistance (strengthening) exercises.
In general, a more gradual progression of exercises following rTSA and for a patient with a severely damaged and repaired or irreparable rotator cuff mechanism who underwent TSA than for a patient with a preoperatively intact cuff.
Activities of Daily Living Limit activities to those that can be performed with the elbow at waist level, such as eating or writing.
Avoid reaching behind the back to tuck in a shirt, reach into a back pocket, or following toileting.
Avoid weight bearing (leaning) on the operated extremity, such as pushing during transfers or when moving in bed, especially the first few weeks after surgery.
Avoid lifting objects with the operated arm.
Support the arm in a sling during extended periods of standing or walking.
Wear the sling while sleeping or outside in crowded areas.
No driving for 4 to 6 weeks.
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Goals and interventions. The first phase of rehabilitation includes the following.24,27,39,47,52,53,102,103,126,198
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Control pain and inflammation.
Use of a sling or splint for comfort.
Use of prescribed analgesic and anti-inflammatory medication.
Use of cryotherapy, especially after exercise.
Maintain mobility of adjacent joints.
Active movements of the spine and scapula (while wearing the shoulder sling and after it can be removed for exercise) to maintain motion and minimize muscle guarding and spasm. Incorporate "shoulder rolls" by elevating, retracting, and then relaxing the scapulae to reinforce an erect posture of the trunk. Emphasize active scapular retraction and spinal extension.
Active ROM of the hand, wrist, and elbow when the arm can be removed from the sling.
Restore shoulder mobility.
Passive or therapist-assisted shoulder motions within the safe ROM limits determined during surgery. With the patient lying supine and the arm slightly away from the side of the trunk on a folded towel and the elbow flexed, perform elevation of the arm in the plane of the scapula to tolerance, external rotation to no more than 30° to 45°, and internal rotation until the forearm rests on the chest.
Pendulum (Codman's) exercises. Encourage the patient to periodically remove the sling and gently swing the arm during ambulation at home.
Later during this phase, progress to supine self-assisted shoulder ROM (elevation and rotation) by assisting with the sound hand and later using a wand or dowel rod. Add horizontal abduction to neutral and adduction across the chest holding a wand.
Self-assisted shoulder ROM with a wand in sitting or standing by performing "gear shift" exercises (see Fig. 17.23), resting the arm on a table and sliding it forward (see Fig. 17.25), or use of an overhead rope-pulley system to lessen the weight of the arm. Remind the patient to maintain an erect trunk when performing assisted shoulder motions while seated or standing.
Self-assisted reaching movements (to the nose, forehead, or over the head as comfort allows) to simulate functional movements.
For some patients, transition to active (unassisted) shoulder ROM is often possible by 4 weeks.
Functional activities with the elbow at waist level, such as hand to face and writing, are permissible.
Minimize muscle inhibition, guarding, and atrophy.
Gentle muscle-setting of shoulder musculature (excluding the internal rotators) with the elbow flexed and the shoulder in the plane of the scapula or neutral. Teach these exercises prior to discharge from the hospital by having the patient practice isometric contractions of the muscles of the sound shoulder. Postpone setting exercises (light isometrics) of the operated shoulder until about 4 to 6 weeks after surgery.
Scapular stabilization exercises in nonweight-bearing positions. Target the serratus anterior and trapezius muscles.
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NOTE: For a patient who underwent TSA with repair of a large tear or rupture of a rotator cuff tendon, it may not be permissible to begin ROM exercises immediately after surgery. When the sling or splint can be removed for exercise, perform only passive or assisted ROM throughout the first phase of rehabilitation. The range of shoulder elevation and external rotation initially permitted may be less than for shoulders that did not require cuff repair. Postpone active (unassisted), antigravity ROM and light isometrics until the second phase (approximately 6 weeks postoperatively, when repaired soft tissues are reasonably well healed).
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Following rTSA, patients have a lifting limit of 1 lb or less for 6 weeks, and external rotation and elevation ROM are limited to 0° to 20° and 90° to 120°, respectively, for 3 months.23,129 In addition, shoulder hyperextension, lifting, and supporting of body weight with the involved shoulder are all precautions following rTSA.23 (Refer to Table 17.3 for additional precautions after rTSA.)
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Criteria to progress. Criteria to advance to the second phase of rehabilitation following TSA are:
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ROM: At least 90° of passive elevation, at least 45° degrees of external rotation, and 70° of internal rotation in the plane of the scapula with minimal pain221 or almost full, passive shoulder motion based on intraoperative measurements with little to no pain.39,103
No pain during resisted, isometric internal rotation of the subscapularis.39
Ability to perform most waist-level activities of daily living (ADLs) without pain.103
For rTSA, criteria include tolerance of assisted ROM and demonstration of the ability to isometrically activate the deltoid and periscapular musculature while the joint is positioned in the scapular plane.23
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Exercise: Moderate Protection/Controlled Motion Phase
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Although suggested timelines vary from one resource to another, the moderate protection/controlled motion phase of rehabilitation, which typically begins at about 4 to 6 weeks postoperatively and extends to at least 12 to 16 weeks, focuses on gradually establishing active (unassisted) control, dynamic stability, and strength of the shoulder while continuing to increase ROM.24,27,47,52,102,103,126,198,221
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PRECAUTIONS: During this phase of rehabilitation, although it is safe to place increasing stresses (stretching or resistance) on periarticular soft tissues, it is important to do so gradually so as not to irritate these tissues, which are continuing to heal. Therefore, continue with short but frequent exercise sessions (preceded by application of heat and followed by cold) and avoid vigorous stretching or resistance exercises or overuse of the involved shoulder during functional activities.
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Goals and interventions. The goals and exercises for this phase of rehabilitation are as follows.
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+
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NOTE: For patients who have had an rTSA, maintain nonweight-bearing precautions for up to 12 weeks postoperatively.23
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Pain-free, low-intensity (submaximal) resisted isometrics of shoulder muscles, particularly the rotator cuff including the subscapularis or any other repaired muscle-tendon units.
Dynamic resistance exercises for the scapula and shoulder musculature (between 0° and 90° of shoulder elevation) using light weights or light-grade elastic resistance. Begin in the supine position to support and stabilize the scapula and progress to the sitting position.
Upper extremity endurance training with stationary ergometer or a portable reciprocal exerciser on a table. Emphasize progressive repetitions to increase muscular and cardiopulmonary endurance.
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Criteria to progress. To advance to the final phase of rehabilitation, a patient should meet the following criteria.
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Full, passive ROM of the shoulder (based on intraoperative ranges)39,103 or at least 130° to 140° of pain-free, passive or assisted shoulder flexion and 120° of abduction.221
In the plane of the scapula, at least 60° pain-free, passive external rotation and 70° internal rotation.221
Active (unassisted), antigravity elevation of the arm to at least 100° to 120° in the plane of the scapula while maintaining joint stability and using appropriate shoulder mechanics, particularly no scapula elevation prior to elevating the arm.221
4/5 strength of rotator cuff and deltoid muscles.52,103
rTSA patients should have documented improvements in function and increasing strength of the deltoid and periscapular muscles prior to progressing to the next phase.23
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Exercise: Minimum Protection/Return to Function Phase
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The minimum protection/return to functional activity phase usually begins around 12 to 16 weeks postoperatively (depending on rotator cuff tissue quality and function) and typically extends for several more months.52,103,221 Pain-free strengthening of the shoulder girdle for dynamic stability and functional use of the upper extremity for progressively more demanding tasks are the primary focuses of this phase. For optimal results, the home exercise program may need to be continued for 6 months or longer, and functional and recreational activities may need to be modified.
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Goals and interventions. Goals and activities for the final phase of rehabilitation include the following.24,27,39,52,53,102,103,221
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Continue to improve or maintain shoulder mobility.
End-range self-stretching.
Grade III joint mobilization and self-mobilization, if appropriate.24,27,39,103
Continue to improve neuromuscular control and muscle performance of the shoulder.
Pain-free, low-load, high-repetition progressive resistive exercise (PRE) of shoulder musculature in anatomical and diagonal planes and in patterns of movement that replicate functional tasks throughout the available ROM. Position the patient in a variety of gravity-resisted positions.
Closed-chain, resisted shoulder exercises, gradually increasing the amount of weight bearing through the upper extremity.
Use of the involved upper extremity for lifting, carrying, pushing, or pulling activities against increasing loads.
Return to most functional activities.
Use of the operated upper extremity for progressively more advanced functional activities.
Recreational activities, such as swimming and golf are possible.
Modification of high-demand, high-impact work-related or recreational activities to avoid imposing excessive forces on the GH joint that could lead to loosening or premature wear of prosthetic implants.
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NOTE: For the patient whose rotator cuff was irreparable or continues to be significantly deficient because of a tenuous repair and who has limited but pain-free shoulder ROM, modification of the environment and use of assistive devices may be necessary for independence in functional activities.
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Outcomes
Over the past 30 years, as patient selection criteria, prosthetic designs, and surgical techniques have been refined, postoperative outcomes after shoulder arthroplasty have improved. Numerous resources suggest that outcomes after TSA, rTSA, or hemiarthroplasty are influenced by many factors, including the type and severity of the underlying pathology, the status of soft tissues (especially the rotator cuff mechanism and subscapularis), the type and quality of the surgical procedure(s) performed, and patient-related factors, such as participation in a postoperative rehabilitation program.34,38,221 The outcomes most often measured in follow-up studies are pain relief, quality of life, passive and active shoulder ROM, and the ability to perform functional activities.
Despite the emphasis in numerous resources that a patient's participation in postoperative rehabilitation is crucial for successful outcomes, there are no studies to support this opinion, because all patients undergoing shoulder arthroplasty are given some form of postoperative exercise instruction. Furthermore, published protocols are routinely modified to meet the needs of individual patients and consequently have not been compared to determine if one protocol yields better outcomes than another.221
Pain relief. A decrease in pain is the most dramatic result of glenohumeral arthroplasty. Almost all patients—regardless of the underlying pathology, the type of arthroplasty, or the design of the prosthetic implants—report complete or substantial relief of shoulder pain and improved functional use of the arm.*
The extent of pain relief has been shown to be associated with the underlying cause(s) of glenohumeral arthritis. Neer and associates,141 Matsen,125 and more recently, Norris and Iannotti153 reported that 90% of patients with primary OA or osteonecrosis had complete or near-complete pain relief after TSA. Similar results have been reported for patients with OA who underwent hemiarthroplasty.115,126,143 Patients with RA or other synovium-based diseases also report substantial pain relief after TSA or hemiarthroplasty, although not quite to the extent reported by patients with OA or osteonecrosis.38,180,206 However, in a sample of 191 patients after rTSA, Wall and colleagues report statistically significant improvements in pain as measured by the Constant score regardless of patient diagnosis.216
Whether TSA is more effective than hemiarthroplasty for pain relief has also been studied. In a prospective follow-up study over a mean of 4.3 years when patients with OA having TSA were compared to those having hemiarthroplasty, postoperative pain scores were reported to be similar in the two groups, with patients in the TSA group demonstrating more improvement because of a higher level of pain preoperatively.157 In another study, patients with OA were randomly assigned to undergo either TSA or hemiarthroplasty and were evaluated postoperatively over a 24-month period. Results of this study indicated that both groups of patients reported significant pain relief and improvements in other quality-of-life parameters, with no significant differences between the TSA and hemiarthroplasty groups.115 Whether TSA versus hemiarthroplasty is more effective for pain relief in patients with RA has not been clearly established.126,206
ROM and functional use of the upper extremity. Despite the emphasis placed on improving ROM and use of the arm for functional activities during rehabilitation after shoulder arthroplasty, improvements in these outcomes are less predictable than pain relief, with the functional status improving more consistently than ROM.† In general, patients with primary OA or osteonecrosis demonstrate greater improvement in active ROM (forward elevation and shoulder rotation) than patients with RA, in part because of a higher incidence of cuff deficiency associated with RA or the use of more constrained prosthetic designs.180,206,221 For example, in patients with OA or osteonecrosis, the mean active forward elevation of the shoulder (reported in reviews of a number of studies) changed from 105° to 161°. In patients with RA, means ranged from 75° to 105°.192,221
Significant improvement in functional status has been reported for patients with OA or osteonecrosis. Although functional improvement after arthroplasty has been reported for patients with RA, many studies used nonstandardized measurement tools, making it difficult to compare their results with those of other studies.221 Following rTSA, patients with primary rotator cuff arthropathy, primary OA with rotator cuff tear, and those with a massive rotator cuff tear had better functional and clinical outcomes than patients with posttraumatic arthritis or revision arthroplasty.216 Regardless of the underlying pathology, resources agree that a well-functioning rotator cuff mechanism is the basis for significant postoperative gains in active ROM and functional abilities.38,189,221
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Painful Shoulder Syndromes (Rotator Cuff Disease and Impingement Syndromes): Nonoperative Management
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Mechanical compression and irritation of the soft tissues (rotator cuff and subacromial bursa) in the suprahumeral space (see Fig. 17.7) is called impingement syndrome and is the most common cause of shoulder pain.83,112,121 Various etiological factors have been identified and therefore, have led to several classification systems, which are summarized in Box 17.7.
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BOX 17.7 Categories of Painful Shoulder Syndromes
Impingement syndromes and other painful shoulder conditions have varying etiologic factors and therefore can be categorized in several ways.
Based on Degree or Stage of Pathology of the Rotator Cuff (Neer's Classification of Rotator Cuff Disease) Stage I. Edema, hemorrhage (patient usually <25 years of age)140
Stage II. Tendonitis/bursitis and fibrosis (patient usually 25 to 40 years of age)
Stage III. Bone spurs and tendon rupture (patient usually >40 years of age)
Based on Impaired Tissue Supraspinatus tendonitis45
Infraspinatus tendonitis
Bicipital tendonitis
Superior glenoid labrum
Subdeltoid (subacromial) bursitis
Other musculotendinous strains (specific to type of injury or trauma)
Anterior—from overuse with racket sports (pectoralis minor, subscapularis, coracobrachialis, short head of biceps strain)
Inferior—from motor vehicle trauma (long head of triceps, serratus anterior strain)
Based on Mechanical Disruption and Direction of Instability or Subluxation Multidirectional instability from lax capsule with or without impingement
Unidirectional instability (anterior, posterior, or inferior) with or without impingement
Based on Progressive Microtrauma (Jobe's classification) Group 1. Pure impingement (usually in an older recreational athlete with partial undersurface rotator cuff tear and subacromial bursitis)98
Group 2. Impingement associated with labral and/or capsular injury, instability, and secondary impingement
Group 3. Hyperelastic soft tissues resulting in anterior or multidirectional instability and impingement (usually attenuated but intact labrum, undersurface rotator cuff tear)
Group 4. Anterior instability without associated impingement (result of trauma; results in partial or complete dislocation)
Based on Degree and Frequency
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Related Pathologies and Etiology of Symptoms
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The cause of impingement is multifactoral, involving both structural and mechanical impairments. Impingement syndrome is often used as the diagnosis when the patient's signs and symptoms are related to pain with overhead reaching, a painful arc mid-range, and positive impingement tests. Other test results may more specifically identify the tissue involved, the faulty mechanics associated with the condition, or the degree of instability or injury. Symptoms that derive from impingement are usually brought on with excessive or repetitive overhead activities that load the shoulder joint, particularly in the mid-range. Impingement syndromes are generally classified as intrinsic or extrinsic, with extrinsic further classified as primary, secondary, and internal.
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Other types of musculotendinous strain in the shoulder region occur as the result of overuse or trauma, such as in the anterior pectoral region from racket sports or in the long head of the triceps and serratus anterior from impact trauma, such as holding onto a steering wheel in an automobile accident.
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Intrinsic Impingement: Rotator Cuff Disease
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Intrinsic factors are those that compromise the integrity of the musculotendinous structures and include vascular changes in the rotator cuff tendons, tissue tension overload, and collagen disorientation and degeneration.65,136 These factors typically involve the articular side of the tendons and may progress to articular-side rotator cuff tears, seen most often in those older than 40 years of age.80
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Extrinsic Impingement: Mechanical Compression of Tissues
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Extrinsic impingement is believed to occur as a result of mechanical wear of the rotator cuff against the anteroinferior one-third of the acromion in the suprahumeral space during elevation activities of the humerus (Fig. 17.15). Encroachment may be the result of anatomical or biomechanical factors that decrease the dimensions of the suprahumeral space. Extrinsic impingement can also occur at the posterior aspect of the supraspinatus tendon, mainly in athletes who throw repetitively.
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Primary extrinsic impingement. Primary extrinsic impingement can result from anatomical or biomechanical factors. Anatomical factors that may cause primary extrinsic impingement include structural variations in the acromion or humeral head, hypertrophic degenerative changes of the AC joint, or other trophic changes in the coracoacromial arch or humeral head. All of these factors decrease the suprahumeral space and often have to be dealt with surgically.65,92,170,238 Biomechanical factors include altered orientation of the clavicle or scapula during movement, or increased anterosuperior humeral head translations as may occur with a tight posterior GH capsule.77
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Neer142 first suggested that the size and shape of the structures that make up the coricoacromial arch are related to rotator cuff impingement. In later studies, variations of the acromion were identified and classified into three shapes: type I (flat), type II (curved), and type III (hooked) (Fig. 17.16).15 Rotator cuff pathology is often associated with types II and III—but not type I—acromial shapes.1,135,238
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Secondary extrinsic impingement. Secondary impingement is used to describe mechanical compression of the suprahumeral tissues due to hypermobility or instability of the GH joint and increased translation of the humeral head. This instability may be multidirectional or unidirectional and can occur with compromised static restraints (GH ligaments) or with dynamic rotator cuff insufficiency (force imbalances or fatigue).
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Multidirectional instability. Some individuals have physiologically increased connective tissue extensibility, causing excessive joint mobility. In the GH joint, this increased extensibility allows larger than normal humeral head translations in all directions.156,181 Many individuals, particularly those involved in overhead activities, develop laxity of the capsule from continually subjecting the joint to stretch forces.65,98 A hypermobile GH joint may be supported satisfactorily by strong rotator cuff muscles; but with muscle fatigue, poor humeral head stabilization leads to faulty humeral mechanics, trauma, and inflammation of the suprahumeral tissues.98,134 With multidirectional instability, the mechanical impingement of tissue in the suprahumeral space is, therefore, a secondary effect of the increased humeral head translations.65
Unidirectional instability with or without impingement. Unidirectional instability (anterior, posterior, or inferior) may be the result of physiological laxity of the connective tissues, but is often the result of trauma and usually involves rotator cuff tears. The tears can be classified as acute, chronic, degenerative, or partial- or full-thickness tears. Often, there is damage to the glenoid labrum and tearing of some of the supporting ligaments.
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Internal extrinsic impingement. Internal impingement is a relatively recent type of extrinsic impingement that occurs in a position of elevation, horizontal abduction, and maximum external rotation, primarily in throwing athletes. This position and a posterior-superior shift of the humeral head on the glenoid results in a mechanical entrapment of the posterior supraspinatus tendon between the humeral head and the labrum. Internal impingement is associated with a combination of posterior GH capsule tightness and scapula kinematic alterations.111,138
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Neer categorizes tendonitis/bursitis as a stage II impingement syndrome (see Box 17.7).140 The following sections describe specific pathological diagnoses and presenting signs and symptoms.
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Supraspinatus tendonitis. With supraspinatus tendonitis, the lesion is usually near the musculotendinous junction, resulting in a painful arc with overhead reaching. There is also pain with impingement tests and pain on palpation of the tendon just inferior to the anterior aspect of the acromion when the patient's hand is placed behind the back. It is difficult to differentiate tendonitis from subdeltoid bursitis because of the anatomical proximity of these two structures.
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Infraspinatus tendonitis. With infraspinatus tendonitis, the lesion is usually near the musculotendinous junction, resulting in a painful arc with overhead, forward, or cross body motions. It may present as a deceleration (eccentric) injury due to overload during repetitive or forceful throwing activities. Pain occurs with palpation of the tendon just inferior to the posterior corner of the acromion when the patient horizontally adducts and externally rotates the humerus.
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Bicipital tendonitis. With bicipital tendonitis, the lesion involves the long tendon in the bicipital groove beneath or just distal to the transverse humeral ligament. Swelling in the boney groove is restrictive and compounds and perpetuates the problem. Pain occurs with Speed's test and on palpation of the bicipital groove.123 Rupture or dislocation of this humeral depressor may escalate impingement of tissues in the suprahumeral space.140,149
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Bursitis (subdeltoid or subacromial). When acute, the symptoms of bursitis are the same as those seen with supraspinatus tendonitis. Once the inflammation is under control, there are no symptoms with resisted motions.
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Other Impaired Musculotendinous Tissues
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The following are examples of other musculotendinous problems in the shoulder region.
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The pectoralis minor, short head of the biceps, and coracobrachialis are subject to microtrauma, particularly in racquet sports requiring a controlled backward, then a rapid forward swinging of the arm. The scapular stabilizers, particularly the retractors, are also susceptible to microtrauma, as they function to control forward motion of the scapula.114
The long head of the triceps and scapular stabilizers may be injured in motor vehicle accidents, as the driver holds firmly to the steering wheel on impact.
Injury, overuse, or repetitive trauma can occur in any muscle being subjected to stress.152 Pain occurs when the involved muscle is lengthened or when contracting against resistance. Palpating the site of the lesion causes the familiar pain.
+++
Insidious (Atraumatic) Onset
++
Neer has identified rotator cuff tears as a stage III impingement syndrome, a condition that typically occurs in persons over age 40 after repetitive microtrauma to the rotator cuff or long head of the biceps.140 With aging, the distal portion of the supraspinatus tendon is particularly vulnerable to impingement or stress from overuse strain. With degenerative changes, calcification and eventual tendon rupture may occur.65,146,155 Chronic ischemia caused from tension on the tendon and decreased healing in the elderly are possible explanations, although Neer stated that, in his experience, 95% of tears are initiated by impingement wear rather than by impaired circulation or trauma.140
+++
Common Structural and Functional Impairments
++
Various impairments have been reported to be common in impingement syndromes; however, it is not known if they are the cause or effect of the faulty mechanics.33,118,121,158,218 A thorough examination of the cervical spine and shoulder girdle is necessary to differentiate signs and symptoms related to primary and secondary impingements or other causes of shoulder pain.22,51,123 Common impairments associated with rotator cuff disease and impingement syndromes are summarized in Box 17.8.
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BOX 17.8 Summary of Common Impairments with Rotator Cuff Disease and Impingement Syndromes
All, some, or none of the following may be present:
Pain at the musculotendinous junction of the involved muscle with palpation, with resisted muscle contraction, and when stretched
Positive impingement sign (forced internal rotation at 90° of flexion) and painful arc
Impaired posture: thoracic kyphosis, forward head, and forward (anterior) tipped scapula with decreased thoracic mobility
Muscle imbalances: hypomobile pectoralis major and minor, levator scapulae, and internal rotators of the GH joint; weak serratus anterior and lateral rotators
Hypomobile posterior GH joint capsule
Hypomobile cervical and/or thoracic spine mobility, especially with secondary impingement.
Faulty kinematics during humeral elevation: decreased posterior tipping of scapula related to weak serratus anterior; scapular elevation and overuse of upper trapezius; and altered scapulohumeral rhythm
With a complete rotator cuff tear, inability to abduct the humerus against gravity
When acute, pain referred to the C5 and C6 reference zones
+++
Impaired Posture and Muscle Imbalances
++
Increased thoracic kyphosis, forward head, and protracted and forward-tilted scapula are often identified as related to impingement syndrome. Faulty scapular alignment may be one factor in decreasing the suprahumeral space and therefore leading to irritation of the rotator cuff tendons with overhead activities.118 Faulty upper quadrant posture leads to an imbalance in the length and strength of the scapular and GH musculature and decreases the effectiveness of the dynamic and passive stabilizing structures of the GH joint.227
++
Typically with increased thoracic kyphosis, the scapula is protracted and tilted forward, and the GH joint is in an internally rotated posture. With this posture, the pectoralis minor, levator scapulae, and shoulder internal rotators are tight; and the external rotators of the shoulder and upward rotators of the scapula may test weak and have poor muscular endurance. When reaching overhead, faulty scapular and humeral mechanics may result in alterations of scapular alignment and in the muscular control of the shoulder complex.
++
FOCUS ON EVIDENCE
In a study that examined the kinematics of 52 subjects (26 without shoulder impairment and 26 with shoulder impingement), Ludewig and Cook118 documented delayed upward rotation of the scapula during the 31° to 60° range of humeral elevation, incomplete posterior tilting of the scapula, and excessive scapular elevation in individuals with impingement compared to those without shoulder impairments. This mechanical alteration may contribute to decreased clearance under the anterior acromion. The investigation also documented decreased activation of the lower serratus anterior and overuse of the upper trapezius with scapular elevation, which was suggested as a possible compensation for the weak posterior tilting action of the serratus anterior.
+++
Decreased Thoracic ROM
++
Thoracic extension is a component motion that is needed for full overhead reaching. Incomplete thoracic extension decreases the functional range of humeral elevation.
++
CLINICAL TIP
Full overhead shoulder movement is more difficult when there is increased thoracic kyphosis and forward head posture. This relationship can be used as an educational tool with a patient to demonstrate the importance of spinal posture. First, have your patient reach overhead while in a slouched posture; then, have him assume "good posture" and reach overhead again and note the difference in ROM. Reinforce the importance of spinal posture in the management and prevention of shoulder problems.
+++
Rotator Cuff Overuse and Fatigue
++
If the rotator cuff musculature or long head of the biceps fatigue from overuse, they no longer provide the dynamic stabilizing, compressive, and translational forces that support the joint and control the normal joint mechanics. This is thought to be a precipitating factor in secondary impingement syndromes when capsular laxity is present and increased muscular stability is necessary for stability.159 The tissues in the subacromial space may then become impinged as a result of faulty mechanics. There is also a relationship between muscle fatigue and joint position sense in the shoulder that may play a role in impaired performance in repetitive overhead activities.35
+++
Muscle Weakness Secondary to Neuropathy
++
Muscle weakness may be related to nerve involvement. Long thoracic nerve palsy has been identified as a cause of faulty scapular mechanics, resulting from serratus anterior muscle weakness, leading to impingement in the suprahumeral region.184
+++
Hypomobile Posterior GH Joint Capsule
++
Tightness in the posterior GH joint capsule compromises the normal arthrokinematics and increases forces on the head of the humerus against the anterior capsule,77 as demonstrated by increased anterior translation in the humeral head when there is a tight posterior capsule.
+++
Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
++
When acute, pain may interfere with sleep, particularly when rolling onto the involved shoulder.
Pain with overhead reaching, pushing, or pulling.
Difficulty lifting loads.
Inability to sustain repetitive shoulder activities (such as reaching, lifting, throwing, pushing, pulling, or swinging the arm).
Difficulty with dressing, particularly putting a shirt on over the head.
+++
Management: Painful Shoulder Syndromes
+
++
NOTE: Even though symptoms may be "chronic" in terms of long standing or recurring, if there is inflammation, the initial treatment priority is to get the inflammation under control.
+++
Management: Protection Phase
+++
Control Inflammation and Promote Healing
++
Modalities and low-intensity cross-fiber massage are applied to the site of the lesion. While applying the modalities, position the extremity to maximally expose the involved region.46,49
Support the arm in a sling for rest.
++
The environment and habits that provoke the symptoms must be modified or avoided completely during this stage. The patient should be informed about the mechanics of the irritation and given guidelines for anticipated recovery with compliance.
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Maintain Integrity and Mobility of the Soft Tissues
++
Passive, active-assistive, or self-assisted ROM is initiated in pain-free ranges.
Multiple-angle muscle setting and protected stabilization exercises are initiated. When exercising the shoulder, it is particularly important to stimulate the stabilizing function of the rotator cuff, biceps brachii, and scapular muscles at an intensity tolerated by the patient.
++
PRECAUTION: It is important to use caution with exercises during this stage to avoid the impingement positions. Often, the mid-range of abduction, with internal rotation, or an end-range position when the involved muscle is on a stretch (such as putting the hand behind the back) provokes a painful response.
+++
Control Pain and Maintain Joint Integrity
++
Pendulum exercises without weights can be used to cause pain-inhibiting grade II joint distraction and oscillation motions (see Fig. 17.22 in the section on exercise).
+++
Develop Support in Related Regions
++
Postural awareness and correction techniques are used. (See related information on 'Interventions for Impaired Posture' in Chapter 14.)
Supportive techniques, such as shoulder strapping or scapular taping, tactile cues, and mirrors, can be used for reinforcement. Repetitive reminders and practice of correct posture are necessary throughout the day.
++
FOCUS ON EVIDENCE
In a randomized placebo-controlled, crossover study,112 of 120 subjects (60 with impingement and 60 without symptoms), changing posture resulted in a significant increase in ROM in flexion, abduction, and arm elevation in the scapular plane; the point in the range at which symptoms were felt was significantly higher. Thoracic and scapular taping had a positive influence in modifying posture; there was less forward head posture, smaller kyphosis, less lateral scapular displacement, less elevated and forward scapula position, and increased, pain-free arm elevation in the scapular plane compared with the measurements taken after placebo taping in both the symptomatic and asymptomatic groups.
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Management: Controlled Motion Phase
++
After the acute symptoms are under control, the main emphasis becomes the use of the involved region with progressive, nondestructive movement and proper mechanics while the tissues heal. The components of the desired functions are analyzed and initiated in a controlled exercise program.48,49,194,223,224,229 If there is functional laxity in the joint, the intervention is directed toward learning neuromuscular control of and developing strength in the stabilizing muscles of both the scapula and glenohumeral joint.30,101,105,183,205 If there is restricted mobility that prevents normal mechanics or interferes with function, mobilization of the restricted tissue is performed. Exercise techniques and progressions are described later in the chapter.
++
Patient adherence to the program and avoidance of irritating the healing tissues are necessary. The home exercise program is progressed as the patient learns safe and effective execution of each exercise. Continue to reinforce proper postural habits.
+++
Develop Strong, Mobile Tissues
++
Manual therapy techniques, such as cross-fiber or friction massage, are used. The extremity is positioned so the tissue is on a stretch if it is a tendon or in the shortened position if it is in the muscle belly. The technique is applied to the tolerance of the patient.
Following massage, the patient is instructed to perform an isometric contraction of the muscle in several positions of the range. The intensity of contraction should not cause pain.
The patient should be taught how to self-administer the massage and isometric techniques.
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Modify Joint Tracking and Mobility
++
Mobilization with movement (MWM) may be useful for modifying joint tracking and reinforcing full movement when there is painful restriction of shoulder elevation because of a painful arc or impingement137 (see Chapter 5 for a description of principles).
++
Posterolateral glide with active elevation (Fig. 17.17 A)
Patient position: Sitting with the arm by the side and head in neutral retraction.
Therapist position and procedure: Stand on the side opposite the affected arm and reach across the patient's torso to stabilize the scapula with the palm of one hand. The other hand is placed over the anteromedial aspect of the head of the humerus. Apply a graded posterolateral glide of the humeral head on the glenoid. Request that the patient perform the previously painful elevation. Maintain the posterolateral glide mobilization throughout both elevation and return to neutral. Ensure that no pain is experienced during the procedure. Adjust the grade and direction of the glide as needed to achieve pain-free function. Add resistance in the form of elastic resistance or a cuff weight to load the muscle.
Self-Treatment. A mobilization belt provides the posterolateral glide while the patient actively elevates the affected limb against progressive resistance to end-range (Fig. 17.17 B).
++
+++
Develop Balance in Length and Strength of Shoulder Girdle Muscles
++
It is important to design a program that specifically addresses the patient's impairments. Typical interventions in the shoulder girdle include but are not limited to:
++
Stretch shortened muscles. Shortened muscles typically include the pectoralis major, pectoralis minor, latissimus dorsi and teres major, subscapularis, and levator scapulae.
Strengthen and train the scapular stabilizers. Scapular stabilizers typically include the serratus anterior and lower trapezius for posterior tipping and upward rotation and the middle trapezius and rhomboids for scapular retraction. It is important that the patient learns to avoid scapular elevation when raising the arm. Therefore, practice scapular depression when abducting and flexing the humerus.
Strengthen and train the rotator cuff muscles. Place emphasis on the shoulder external rotators.
+++
Develop Muscular Stabilization and Endurance
++
Alternating isometric resistance is applied to the scapular muscles in open-chain positions (side-lying, sitting, supine), including protraction/retraction, elevation/depression, and upward/downward rotation, so the patient learns to stabilize the scapula against the outside forces (see Fig. 17.37 in the exercise section).
Scapular and glenohumeral patterns are combined using flexion, abduction, and rotation. Alternating isometric resistance is applied to the humerus while the patient holds against the changing directions of the resistance force (see Figs. 17.38, 17.39, and 17.42 in the exercise section).
Closed-chain stabilization is performed with the patient's hands fixated against a wall, a table, or the floor (quadruped position) while the therapist provides a graded, alternating isometric resistance or rhythmic stabilization. Observe for abnormal scapular winging. If abnormal scapular winging occurs, the scapular stabilizers are not strong enough for the demand, so the position should be changed to reduce the amount of body weight (see Fig. 17.43 in the exercise section).
Muscular endurance is progressed by increasing the amount of time the individual holds the pattern against the alternating resistance. The limit is reached when any one of the muscles in the pattern can no longer maintain the desired hold. The goal at this phase should be stabilization for approximately 3 minutes.
+++
Progress Shoulder Function
++
As the patient develops strength in the weakened muscles, it becomes important to develop a balance in strength of all shoulder and scapular muscles within the range and tolerance of each muscle. To increase coordination between scapular and arm motions, dynamically load the upper extremity within tolerance of the synergy with submaximal resistance. To improve muscular endurance, have the patient increase control from 1 minute to 3 minutes.
+++
Management: Return to Function Phase
++
Specificity of training toward the desired functional outcome begins as soon as the patient has developed control of posture and the basic components of the desired activities without exacerbating the symptoms. While working with the patient, continue to teach him or her how to progress the program when discharged and how to prevent recurrences. Suggestions are summarized in Box 17.9.
++
BOX 17.9 Patient Instructions to Prevent Recurrences of Shoulder Pain
Prior to exercise or work, massage the involved tendon or muscle; follow with isometric resistance and then with full ROM and stretching of the muscle.
Take breaks from the activity if repetitive in nature. If possible, alternate the stressful, provoking activity with other activities or patterns of motion.
Maintain good postural alignment; adapt seating or workstation to minimize stress. If sport-related, seek coaching in proper techniques or adapt equipment for safe mechanics.
Prior to initiating a new activity or returning to an activity for which not conditioned, begin a strengthening and training program.
+++
Increase Muscular Endurance
++
To increase muscular endurance, repetitive loading of the defined patterns is increased from 3 minutes to 5 minutes.
+++
Develop Quick Motor Responses to Imposed Stresses
++
+++
Progress Functional Training
++
Specificity of training progresses to an emphasis on timing and sequencing of events.
++
Eccentric training is progressed to maximum load.
Desired functional activities are simulated—first under controlled conditions, then under progressively challenging conditions using acceleration/deceleration drills.
The patient is involved in assessing performance in terms of safety, symptom provocation, postural control, and ease of execution and then practices adaptations to correct any problems.
+++
Painful Shoulder Syndromes: Surgery and Postoperative Management
++
Surgical intervention is an option for painful shoulder syndromes when conservative management does not resolve symptoms and improve function. For an individual with primary impingement as a result of structural variations in the acromion (see descriptions and Fig. 17.16 in the previous section), subacromial decompression may be performed. An individual with a partial- or full-thickness rotator cuff tear may require surgical repair.
+++
Subacromial Decompression and Postoperative Management
++
When pain and loss of functional mobility associated with primary impingement do not resolve sufficiently with nonoperative management, subacromial decompression, designed to increase the volume of the subacromial space and provide adequate gliding room for tendons, is often warranted. Subacromial decompression also is referred to as anterior acromioplasty or decompression acromioplasty. However, acromioplasty, which alters the shape of the acromion, is typically, but not always, one of the components of subacromial decompression.128
+++
Indications for Surgery
++
The following are generally accepted indications for surgical management of impingement syndromes.*
++
Pain during overhead activities and loss of functional mobility of the shoulder as the result of primary impingement that persists (typically for 3 to 6 months or longer) despite a trial of nonoperative interventions.
Stage II (Neer classification; see Box 17.7) impingement with nonreversible fibrosis or boney alterations of the subacromial compartment, calcific deposits in the cuff tendons, and symptomatic subacromial crepitus.
Intact or minor tear of the rotator cuff.
+
++
NOTE: Patients who present with secondary impingement (GH joint hypermobility or instability associated with a partial-or full-thickness tear of the rotator cuff) are not candidates for surgical subacromial decompression alone. For these patients, subacromial decompression is combined with concomitant repair of the cuff tear; otherwise, the procedures inherent in subacromial decompression can worsen GH instability.79,128,215
++
Surgical approach. Subacromial decompression is performed using an arthroscopic or open approach. Although an open approach has been used successfully for many years,84,139,142,170 the preferred procedure today in most cases is an arthroscopic approach.59,215 Unlike a traditional open approach, in which the proximal attachment of the deltoid must be detached and then repaired prior to closure,142 with an arthroscopic approach, the deltoid remains intact, enabling the patient to regain functional use of the upper extremity more rapidly after surgery. For the most part, the traditional open approach for subacromial decompression is now reserved for some patients with a massive rotator cuff tear who also are undergoing an open repair. Another option preferred by some surgeons is a "mini-open" approach, which involves splitting the deltoid insertion vertically rather than detaching it.128
++
Component procedures. There are several surgical procedures that can be performed for subacromial decompression, depending on the pathology observed during examination of the shoulder prior to or during surgery.1,59,75,79,128,154,176,215
++
Removal of the subacromial bursa (bursectomy), which is typically thickened (enlarged) by chronic inflammation
Release of the coracoacromial ligament, which is usually hypertrophied and may also be frayed, followed by complete or partial resection or recession
Resection of the anterior acromial protuberance and contouring the undersurface of the remaining portion of the acromion (acromioplasty) to enlarge the subacromial space (Fig. 17.18)
Removal of any osteophytes at the AC joint and in some cases resection of the distal portion of the clavicle for advanced arthritis of the AC joint
++
+++
Postoperative Management
++
The type of surgical approach used and the status of the rotator cuff significantly affect rehabilitation decisions after subacromial decompression. If the rotator cuff is intact preoperatively, rehabilitation after arthroscopic decompression progresses quite rapidly because the shoulder musculature is left intact during the procedure. In contrast, if a repair of the rotator cuff is required in addition to decompression, or a mini-open or open approach is used, rehabilitation progresses at a slower rate to allow the repaired shoulder musculature adequate time to heal.
+
++
NOTE: The guidelines outlined in this section are for postoperative rehabilitation after arthroscopic subacromial decompression for a patient with primary shoulder impingement who has an intact rotator cuff. If subacromial decompression is combined with repair of the rotator cuff, the guidelines presented in a later section of this chapter on rehabilitation after rotator cuff repair are appropriate.
++
The shoulder is immobilized and supported in a sling with the arm positioned at the patient's side or in slight abduction; the shoulder is internally rotated; and the elbow is flexed to 90°. The sling is worn for comfort for 1 to 2 weeks but is removed for exercise the day after surgery.128,215,225
++
Exercise interventions after subacromial decompression targets many of the impairments noted for rotator cuff impingement discussed previously in this chapter. This information merits review to understand why specific exercises are included in the postoperative rehabilitation program.
++
Because arthroscopic decompression is often performed on an outpatient basis, a patient initially may need to carry out the prescribed exercises at home with little supervision and then follow up with a series of outpatient therapy visits at a later time. Therefore, patient education is of the utmost importance for each phase of rehabilitation.
+++
Exercise: Maximum Protection Phase
++
The first phase of rehabilitation after arthroscopic decompression begins on the day after surgery and extends for 3 to 4 weeks. Emphasis is placed on pain control and immediate but comfortable assisted movement of the shoulder to prevent adhesions of the cuff tendons in the subacromial space. Attaining full or nearly full passive ROM of the operated shoulder (compared to the noninvolved shoulder) is a reasonable goal by 4 to 6 weeks postoperatively.79
++
Patient education begins immediately and is directed toward helping the patient recognize and avoid postures that contribute to symptoms during exercise and ADL. Active (unassisted) shoulder ROM is permissible as soon as motions are pain-free and proper scapulothoracic and glenohumeral control can be maintained. This may be possible as early as 2 weeks postsurgery.
++
Goals and interventions. The following goals and exercises are indicated for the early stage of tissue healing.1,3,39,79,128,225
++
Control pain and inflammation.
Use of a sling when the arm is dependent.
Use of cryotherapy and prescribed anti-inflammatory medication.
Shoulder relaxation exercises.
Prevent loss of mobility of adjacent regions.
Develop postural awareness and control.
Active movement of the scapula with emphasis on retraction.
Posture training, emphasizing cervical retraction, thoracic extension, scapula retraction and a neutral lumbo-pelvic complex.
Restore pain-free shoulder mobility.
Assisted shoulder ROM as tolerated by pain, initially guiding with the sound upper extremity and later a wand. Start in the supine position to provide additional stability to the scapula against the thorax and with the upper arm on a folded towel in slight abduction and flexion. Shoulder motions include elevating the arm in the plane of the scapula, forward flexion, abduction, rotation, and horizontal abduction and adduction. Progress to performing exercises in a semi-reclining position and then in a seated or standing position while maintaining thoracic extension.
Assisted shoulder extension in a standing position with a wand held behind the back.
Stretching the posterior shoulder structures in pain-free range using a cross-chest stretch into horizontal adduction. Postpone until next phase if painful.
Active ROM (unassisted) of the shoulder and scapula within pain-free ranges, maintaining proper scapulothoracic and glenohumeral control; begin supine and progress to sitting. Active shoulder motions may be possible by 2 weeks postoperatively.
Prevent reflex inhibition and atrophy of shoulder girdle musculature.
Pain-free, low-intensity, multiple-angle isometrics of GH musculature with the arm supported and emphasis on the rotator cuff against minimal resistance. Begin submaximal isometrics a week or so postoperatively. Lightly resist with the uninvolved upper extremity. Focus on increasing repetitions more than resistance.118,184
Submaximal alternating isometric and rhythmic stabilization exercises for scapulothoracic muscles with the involved arm supported by the therapist. Target the scapular retractors and upward rotators.
++
Criteria to progress. Criteria to advance to the second phase include39,79,102,128,225:
++
Minimal discomfort when the shoulder is unsupported; arm swing is comparable to opposite arm during ambulation.
Almost full, pain-free, passive ROM of the shoulder (full mobility of the scapula; at least 150° of arm elevation; full internal/external rotation).
In the supine position, pain-free active elevation of the arm well above the level of the shoulder.
Pain-free, active external rotation of the shoulder to about 45°.
At least fair (3/5) and preferably good (4/5) muscle testing grade of shoulder musculature.
+++
Exercise: Moderate Protection Phase
++
Exercises during the second phase of rehabilitation are directed toward attaining full, pain-free shoulder ROM and improving neuromuscular control and muscle performance (strength, muscular endurance) of the rotator cuff, scapular stabilizers, and prime movers. The patient may be ready to begin this phase of rehabilitation as early as 3 to 4 weeks postoperatively but more often by 4 to 6 weeks. This phase extends over a 4- to 6-week period or until the patient meets the criteria to progress to the next phase.
++
Goals and interventions. The goals, exercises, and activities during the second phase of rehabilitation are39,79,102,225:
++
Restore and maintain full, pain-free passive mobility of the shoulder girdle and upper trunk.
Joint mobilization emphasizing posterior and caudal glides of the humerus and scapulothoracic mobility.
Low-intensity self-stretching of muscles that could restrict sufficient upward rotation of the scapula and rotation of the humerus, specifically the levator scapulae, rhomboids, middle trapezius, subscapularis, latissimus dorsi, and pectoralis major and minor. Recall that tightness of these muscles may contribute to subacromial impingement during overhead movements of the arm.
Self-stretching of the posterior shoulder muscles and posterior capsule of the GH joint, as these structures may be tight in the presence of shoulder impingement.
Self-stretch of the upper trunk by lying supine on a rolled towel placed vertically between the scapulae.
Performance of exercises and functional movement patterns during ADL into the increased ROM.
Reinforce posture awareness and control.
Develop dynamic stability, strength, endurance, and control of scapulothoracic and GH muscles.
Stabilization exercises against increasing resistance and in weight-bearing positions. Emphasize isolated strengthening of the serratus anterior and trapezius muscles.
Upper extremity ergometry for muscular endurance. To avoid an impingement arc, initiate in a standing position rather than while seated.
Dynamic strengthening exercises of isolated shoulder muscles against low-loads (1- to 5-lb weight or light-grade elastic tubing), gradually increasing repetitions. Begin resisted elevation of the arm in the supine position to stabilize the scapula against the thorax; progress to sitting or standing.
Use the involved arm for functional activities that involve light resistance.
++
CLINICAL TIP
Target the upward rotators of the scapulothoracic joint (serratus anterior, upper and lower trapezius) and the rotator cuff muscles187 as well as the latissimus dorsi, teres major, and biceps brachii, which act as humeral head depressors and therefore, oppose superior translation during active elevation of the arm. Initially, perform resisted motions of the humerus below the level of the shoulder; later, progress to overhead exercises if motions remain pain-free.
++
PRECAUTION: Be certain the patient can perform active shoulder flexion and abduction against gravity without elevating the scapula before progressing to resisted exercises above shoulder level.
++
Criteria to progress. The criteria to progress to the final phase of rehabilitation are39,102,225:
++
Negative impingement tests.
Full, pain-free, active ROM of the shoulder without evidence of substitute motions.
At least 75% strength of the shoulder musculature compared with the sound shoulder.225
+++
Exercise: Minimum Protection/Return to Function Phase
++
The final phase of rehabilitation usually begins 8 weeks postoperatively, at which time soft tissues are reasonably well healed and require little to no protection. Exercises continue until about 12 to 16 weeks postoperatively or until the patient has returned to full activity. Exercises are directed toward continuing to improve strength and endurance of the shoulder girdle muscles using isolated movements and those that simulate functional activities. Patients often see continued improvement in functional use of the operated upper extremity for 6 months postoperatively.3
++
The time necessary for full recovery and unrestricted activities depends largely on the level of demand of the anticipated activities. A patient wishing to return to competitive sports requires a more demanding progression of advanced exercises (e.g., plyometric training and sport-specific drills) than a sedentary individual.39,225,228
++
Goals and interventions. The goals, exercises, and activities during the final phase of rehabilitation after subacromial decompression are similar to the final phase of nonoperative management of primary impingement syndrome. Refer to the information presented in the previous section of this chapter as well as other resources.39,49,223,225,228
++
Outcomes
There appears to be no significant difference in the long-term results (pain-free ROM and return to desired functional activities) after either open or arthroscopic surgery for primary impingement syndrome with or without associated rotator cuff disease.59,128,215 Based on the results of numerous outcome studies of open and arthroscopic procedures, 85% to 95% of patients report good to excellent results 1.0 to 2.5 years postoperatively.1,79,128,215 In general, patients reporting the least satisfaction with their function after surgery are those who participate in high-demand athletic activities that involve overhead throwing and those with work-related injuries who are receiving workers' compensation.128
Follow-up studies have documented several advantages to having an arthroscopic rather than comparable open surgical management of impingement syndrome. Advantages include less postoperative pain; earlier restoration of full ROM and strength; earlier return to work (often as early as 1 week postoperatively); lower cost (shorter hospital stay or outpatient surgery); and a more favorable cosmetic result.1,79,128,215
Although exercises are routinely prescribed after subacromial decompression, the effectiveness of exercise has been the focus of very few studies. One prospective, randomized study carried out in Denmark looked at the effectiveness of a 6-week therapist-supervised exercise program compared to a self-managed program after arthroscopic subacromial decompression.3 Patients in the therapist-supervised group received exercise instruction while in the hospital and then for a 1-hour therapy session once a week for 6 weeks after discharge from the hospital. Patients in the self-managed group received exercise instruction on one occasion prior to discharge from the hospital. Both groups received written instructions. At 6 weeks and at 3, 6, and 12 months, all of the patients demonstrated improvement in the parameters tested. However, there were no significant differences between the two groups with the exception of one measurement. At 3 months postoperatively, the therapist-supervised group had a higher level of pain than the self-managed group. The authors concluded that initial, therapist-directed exercise instruction followed by a home-based, self-managed exercise program achieved rehabilitation goals as effectively as a therapist-supervised program.
+++
Rotator Cuff Repair and Postoperative Management
++
There are two broad categories of rotator cuff tears, defined by the depth of the tendon tear: partial-thickness and full-thickness tears. Either type may require surgical management. A partial-thickness tear extends inferiorly or superiorly through only a portion of the tendon from either the acromial (bursal) or humeral (articular) surface of the tendon. A full-thickness tear is a complete tear, which extends the entire depth of the tendon.79,87,128
+++
Indications for Surgery
++
The primary indications for surgical management of a rotator cuff tear confirmed by imaging are pain and impaired function as the result of the following.*
++
Partial-thickness or full-thickness tears of the rotator cuff tendons with irreversible, degenerative changes in soft tissues. Some patients with Neer stage II lesions and most with Neer stage III lesions who continue to be symptomatic and have functional limitations after a trial of nonoperative treatment are candidates for surgery.
Acute, traumatic rupture of the rotator cuff tendons often combined with avulsion of the greater tuberosity, labral damage, or acute dislocation of the GH joint in individuals with no known history of prior cuff injury. Full-thickness, traumatic tears occur most often in young, active adults.
+
++
NOTE: Surgical repair is not indicated in patients who are asymptomatic despite the presence of a cuff tear confirmed by imaging.
++
There are several operative options for repairing a torn rotator cuff, including arthroscopic, open, and mini-open repairs.68,79,81,128,215 The decision about which option to choose depends on the severity and location of the tear, the number of tendons involved, the extent of associated lesions, the type of onset (repetitive microtrauma or traumatic injury), the quality and mobility of the torn tissues, bone quality, patient-related considerations (age, health, activity level), and the surgeon's preference and experience.
++
The type of cuff repair is typically classified by the surgical approach and techniques used. There are three categories of repair.†
++
Arthroscopic approach. The entire procedure is performed arthroscopically and requires only a few small incisions for port sites.
Mini-open (arthroscopically assisted) approach. There are two variations of this type of procedure, both of which involve arthroscopic subacromial decompression and a deltoid-splitting approach. In one variation, only the subacromial decompression is performed arthroscopically, whereas in the other variation a portion of the cuff repair itself is also performed arthroscopically.236 In both cases, an anterolateral incision is made at the acromion and is extended distally (either 1.5 or 3.5 cm but no more than 4 cm to avoid the axillary nerve) along the fibers of the deltoid insertion. The deltoid is split longitudinally between its anterior and middle portions to allow visualization of the cuff tear without detaching the deltoid from its proximal insertion.62,68,128,160,204
Traditional open approach. An anterolateral incision is made that extends obliquely from the middle one-third of the inferior aspect of the clavicle, across the coracoid process, and to the anterior aspect of the proximal humerus. The proximal insertion of the deltoid must be detached and reflected for exposure of the operative field during an open subacromial decompression and cuff repair. After the cuff repair is complete, the deltoid is reattached to the acromion.* As arthroscopic and arthroscopically assisted repairs of the rototor cuff have advanced, the use of the traditional open approach has decreased.
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Components of a Rotator Cuff Repair
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Regardless of the approach, subacromial decompression is performed (particularly for cuff tears associated with chronic impingement) before repair of the cuff is undertaken. After the tear is visualized, the margins of the torn tendon are débrided and released from any adherent soft tissues. Then the cuff tendon is mobilized for advancement and apposition to bone that has been prepared for sutures and is attached by tendon-to-bone fixation. Depending on whether an arthroscopic or mini-open approach is used, fixation is accomplished by sutures and suture anchors, tacks, or staples.62,66,79,128,203,215
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In addition to subacromial decompression, other concomitant procedures may be required. For example, capsular tightening or labral reconstruction may be performed if unidirectional or multidirectional instability of the GH joint is present. Because degenerative changes in the tendon of the long head of the biceps brachii are often associated with chronic rotator cuff disease, a repair of this tendon also may be necessary.
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Selection of Surgical Procedures
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The surgeon weighs many factors when determining which type of cuff repair is most appropriate for each patient. One such consideration is the severity of the tear, including thickness (partial or full), size, and number of tendons torn. Although there is some variability in the literature, there are four generally accepted categories that describe the longitudinal size of rotator cuff tears: small (1 cm or less), medium (1 to 3 cm), large (3 to 5 cm), and massive (more than 5 cm or a full-thickness tear of more than one tendon).8,62,79,217
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A small, partial-thickness cuff tear is usually managed surgically with a fully arthroscopic approach to débride the frayed margins of the torn tendon and includes a subacromial decompression. The torn portion of the tendon may or may not be repaired.8,79,128,195,203,215
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Two decades ago, primarily small and medium full-thickness cuff tears were managed with a fully arthroscopic approach.67,79,128 With the evolution of arthroscopic techniques, an increasing number of large, full-thickness tears and some massive tears are managed with a fully arthroscopic approach.215,236 However, variations of the mini-open (deltoid splitting) approach are frequently the surgeon's choice for repair of medium and large tears.62,128,204 Even some massive tears are managed with a deltoid-splitting approach.128,217 The traditional open approach, requiring detachment and repair of the deltoid, is now primarily reserved for repairs of multiple tendon tears associated with extensive injury to the shoulder.62,128
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The location of the cuff tear, amount of retraction and mobility of a full-thickness tear, and the quality of the remaining tendon and underlying bone also influence the surgeon's selection of the type of cuff repair expected to be most effective.79,128,203,215 Whereas small, medium, and large tears of the supraspinatus or infraspinatus are routinely managed with arthroscopic or mini-open approaches, tears of the subscapularis are often managed with a traditional open approach.62 If there is significant retraction and poor mobility of the torn tendon or poor tissue quality, many surgeons believe that a stronger repair can be achieved with an open procedure than an arthroscopic repair.79
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Postoperative Management
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After surgical repair of a torn rotator cuff tendon, there are many factors that influence decisions about the position and duration of immobilization, the selection and application of exercises, and the rate of progression of each patient's postoperative rehabilitation program. These factors and their potential impact are summarized in Table 17.4. These factors also will affect postoperative prognosis and outcomes.
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There is little consensus in the literature or in clinical practice as to how and to what extent each of these factors, singularly or collectively, has an impact on the decisions made by the surgeon and the therapist about a patient's postoperative rehabilitation program. Hence, predetermined guidelines and protocols for postoperative management after rotator cuff repair are diverse and sometimes contradictory.* For example, some authors have pointed out that if deltoid detachment and repair are components of the surgery, as is necessary for a traditional open repair, deltoid strengthening exercises should be postponed for approximately 6 to 8 weeks postoperatively until the repaired deltoid has healed.39,58,128 Yet another author suggested that rehabilitation should proceed similarly regardless of whether deltoid detachment was required so long as secure fixation of the deltoid was achieved.77
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Given the diverse characteristics of patients undergoing rotator cuff repair and the variety of surgical options available, it is not surprising that no single postoperative program can be used for all patients or has been shown to yield better outcomes than another. Therefore, to meet each patient's needs and goals, a therapist can use published protocols or those developed at individual clinical facilities as general guidelines for postoperative management. Modifications to protocols and guidelines should be made based on ongoing examination of the patient's response to interventions and through close communication with the surgeon.
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Despite variations among postoperative programs, they share three common elements: (1) immediate or early postoperative motion of the GH joint; (2) control of the rotator cuff for dynamic stability; and (3) gradual restoration of strength and muscular endurance. This section will present general exercise guidelines that incorporate these elements into the phases of rehabilitation after arthroscopic or mini-open repair of a full-thickness cuff tear. Potential modifications and precautions due to a traditional open procedure or on factors such as size, location of the tear, and the quality of the repair will be noted.
+
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NOTE: The goals, exercise interventions, and progression of rehabilitation after débridement rather than repair of a partial-thickness tear are comparable to postoperative management after subacromial decompression for cuff impingement presented in the previous section of this chapter.
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The position and duration of immobilization of the operated shoulder after rotator cuff repair depends on many factors, including the size, severity, and location of the tear and the type and quality of the repair. The size of the cuff tear partially determines whether the patient's operated arm is supported in a sling (shoulder adducted, internally rotated, and elbow flexed to 90°) or in an abduction orthosis or pillow (shoulder elevated in the plane of the scapula approximately 45°, shoulder internally rotated, and elbow flexed). Patients supported in an abduction splint may require assistance from a family member to support the operated arm in the 45° shoulder position when the splint is removed for exercise, dressing, or bathing.
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Table 17.5 summarizes the immobilization recommendations for fully arthroscopic and mini-open/deltoid-splitting approaches. Immobilization after a traditional open procedure that involves deltoid detachment and repair is not included in Table 17.5 because of the variations in guidelines reported in the literature.39,79,128,217
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The rationale for initially immobilizing the shoulder in abduction is based on two principles. (1) In the abducted position, the repaired shoulder is held in a more relaxed, neutral position, reducing the possibility of reflexive muscle contractions that could disrupt the repairs. (2) Supporting the arm in abduction, rather than adduction, reduces tension on the tendons and, therefore, may improve blood flow to the repaired tendon(s).
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Regardless of whether a patient undergoes a rotator cuff repair on an inpatient or outpatient basis, contact with a therapist for exercise instruction after surgery is usually limited to a few visits unless the patient does not progress satisfactorily. Therefore, the emphasis of a therapist's interaction with a patient must be placed on patient education for an effective and safe home-based exercise program.
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FOCUS ON EVIDENCE
In a randomized, controlled study by Roddey and colleagues,171 two approaches to exercise instruction following arthroscopic repair of a full-thickness rotator cuff tear were compared, specifically in-person instruction by a therapist and video-based instruction. On the first postoperative day, both groups of patients (total 108) received one visit from the therapist for initial instruction in the postoperative program (sling use and passive shoulder exercises). Patients in both groups received written handouts about the home exercise program. In addition, patients in the video-instruction group received a video demonstrating exercises for all phases of the rehabilitation program.
After discharge, patients in the video group saw the therapist four times (at 2, 6, 12, and 24 weeks) for evaluation and approval to advance to the next phase of rehabilitation, but they received all exercise instruction by watching the video at home. Patients in the other group also saw the therapist four times at identical intervals after discharge for follow-up evaluations and one-to-one instructions from the therapist on how to perform the exercises during the next phase of the home program. Between visits both groups had telephone access to their therapist for questions, and at 52 weeks, all patients were evaluated a final time.
Results of this study indicated that there were no significant differences between the two groups in compliance with the exercise program and functional outomes measured with a self-report instrument. The authors concluded that video-based exercise instruction was equally effective as therapist-directed exercise instruction. It is important to note that 30% of the patients dropped out of the study. The authors did not report whether these patients were progresssing well or if any of them left the study to seek individualized or more frequent therapy.
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Goals and interventions for each phase of rehabilitation after arthroscopic or mini-open cuff repair follow. General guidelines for exercise and precautions after rotator cuff repair are summarized in Box 17.10. Precautions specific to a particular type of cuff tear or surgical procedure are also noted. The suggested timelines for each phase are general and must be adjusted based on factors already noted (see Table 17.4).
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BOX 17.10 General Exercise Guidelines and Precautions Following Repair of a Full-Thickness Rotator Cuff Tear Early Shoulder Motion
Perform passive or assisted shoulder ROM within safe and pain-free ranges based on the surgeon's intraoperative observation of the mobility and strength of the repair and the patient's comfort level during exercise.
Only passive, nonassisted ROM for 6 to 8 weeks after repair of a massive cuff tear or after a traditional open approach to prevent avulsion of the repaired deltoid.
Initially perform passive and assisted shoulder ROM in the supine position to maintain stability of the scapula on the thorax.
Minimize anterior and superior translations of the humeral head and the potential for impingement. Position the humerus slightly anterior to the frontal plane of the body and in slight abduction
While at rest in the supine position, support the distal humerus on a folded towel.
When initiating passive or assisted shoulder rotation while lying supine, position the shoulder in slight flexion and approximately 45° of abduction.
When initiating assisted shoulder extension, perform the exercise in prone (arm over the edge of the bed) from 90° to just short of neutral. Later progress to exercises behind the back.
When performing assisted or active exercises in the upright position (sitting or standing), be certain that the patient maintains an erect trunk posture to minimize the possibility of impingement.
To ensure adequate humeral depression and avoid superior translation of the head of the humerus when beginning active elevation of the arm, restore strength in the rotator cuff, especially the supraspinatus and infraspinatus muscles, before dynamically strengthening the shoulder flexors and abductors.
Do not allow active shoulder flexion or abduction until the patient can lift the arm without hiking the shoulder.
Strengthening Exercises When beginning isometric resistance to scapulothoracic musculature, be sure to support the operated arm to avoid excessive tension in repaired GH musculature.
Use low exercise loads; resisted motions should not cause pain.
No weight-bearing (closed-chain) exercises or activities for 6 weeks.
Delay dynamic strengthening (progressive resistive exercise, or PRE) for a minimum of 8 weeks postoperatively for small, strong repair and for at least 3 months for larger tears.
If the supraspinatus or infraspinatus was repaired, proceed cautiously when resisting external rotation.
If the subscapularis was repaired, proceed cautiously with resisted internal rotation.
After an open repair, postpone isometric resistance exercises to the repaired deltoid and cuff musculature for at least 6 to 8 weeks unless advised otherwise.
Stretching Exercises Avoid vigorous stretching, the use of contract-relax procedures, or grade III joint mobilizations for at least 6 weeks and often for 12 weeks postoperatively to give time for the repaired tendon(s) to heal and become strong.
If the supraspinatus or infraspinatus was repaired, initially avoid end-range stretching into internal rotation.
If the subscapularis was repaired, initially avoid end-range stretching into external rotation.
If the deltoid was detached and repaired, initially avoid end-range shoulder extension, adduction, and horizontal adduction.
Activities of Daily Living Wait until about 6 weeks after a mini-open or arthroscopic repair and 12 weeks after a traditional open repair before using the operated arm for light functional activities.
After repair of a large or massive cuff tear, avoid use of operated arm for functional activities that involve heavy resistance (pushing, pulling, lifting, carrying heavy loads) for 6 to 12 months postoperatively.
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Exercise: Maximum Protection Phase
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The priorities during the initial phase of rehabilitation are to protect the repaired tendon, which is at its weakest approximately 3 weeks after repair,203 and to prevent the potential adverse effects of immobilization. For almost all patients, the immobilization (sling or splint) is removed for brief sessions of passive or assisted ROM within limited (protected) and comfortable ranges during the first few days after surgery (see Table 17.5).
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The maximum protection phase extends for as little as 3 to 4 weeks after a fully arthroscopic or mini-open repair of small or medium tears or as long as 6 to 8 weeks after repair of large or massive tears. After a fully arthroscopic repair of a small or medium cuff tear, every effort is made to attain nearly full passive shoulder ROM, particularly elevation and external rotation, by 6 to 8 weeks postoperatively.62,128,215
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Goals and interventions. The following goals and selected interventions combined with the appropriate use of pain medication are initiated during the maximum protection phase.*
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Control pain and inflammation.
Prevent loss of mobility of adjacent regions.
Assisted ROM of the elbow.
Active ROM of the cervical spine, wrist, and hand.
Prevent shoulder stiffness/restore shoulder mobility.
Pendulum exercises typically the first postoperative day or when the immobilizer may be removed for exercise.
Passive ROM of the shoulder within safe and pain-free ranges. Initially perform exercises in the supine position; begin both arm elevation and external rotation in the plane of the scapula.
Self-assisted ROM using the opposite hand or a wand for control by 1 to 2 weeks for patients with repairs of small to medium tears and about 2 weeks later for patients with repairs of large tears.
Active control of the shoulder with assistance as needed from the therapist or family members. With the patient lying supine, place the arm in 90° of shoulder flexion if pain-free. In this position, the effect of gravity on the shoulder musculature is minimal. This position has been called the "balance point position" of the shoulder.56 Help the patient control the shoulder while moving to and from the balance point position, making small arcs and circles with the arm.
Active shoulder ROM by the latter part of this phase for small tears and as symptoms permit, initially supine with the elbow flexed, progressing to a semi-reclining position with the elbow less flexed.
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PRECAUTION: Use only passive, nonassisted ROM for 6 to 8 weeks for a repair of a massive cuff tear or after a traditional open repair with deltoid detachment.39,217
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Prevent or correct postural deviations.
Develop control of scapulothoracic stabilizers.
Active movements of the scapula.
Submaximal isometrics to isolated scapular muscles.118 To avoid excessive tension in repaired GH musculature, see that the operated arm is supported but not bearing weight.
Side-lying scapular protraction/retraction to emphasize control of the serratus anterior.
Prevent inhibition and atrophy of GH musculature.
Low-intensity, muscle-setting exercises (against minimal resistance). Setting exercises should not provoke pain in a healing cuff tendon. Begin as early as 1 to 3 weeks post-operatively depending on the size of the tear and quality of the repair.39,56,58
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PRECAUTION: Recommendations for the safest position of the shoulder in which to begin isometric training of the GH musculature after cuff repair are inconsistent. Perhaps the safest suggestion is to start in a position that creates minimal tension on the repaired cuff tendons (shoulder internally rotated and flexed and abducted to about 45° and elbow flexed).58 As the strength of the cuff muscles improves during the later phases of rehabilitation, exercises and activities can be performed with the arm positioned in more challenging and functional positions.
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Criteria to progress. Criteria to advance to the second phase include:
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Exercise: Moderate Protection Phase
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The focus of the second phase of rehabilitation is to begin to develop neuromuscular control, strength, and endurance of the shoulder while continuing to attain full or nearly full, pain-free shoulder motion. Emphasis is placed on developing control of the scapular stabilizers and rotator cuff muscles.
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For a patient with a repair of a small or medium tear, this phase begins around 4 to 6 weeks postoperatively and extends an additional 6 weeks. For most patients, strengthening exercises typically begin around 8 weeks postoperatively. This phase may begin as late as 12 weeks for a patient with a repair of a large or massive tear.
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FOCUS ON EVIDENCE
In a descriptive study by Ellenbecker and colleagues,56 patients (n = 37) who had undergone a mini-open repair for full-thickness cuff tears (small, medium, and large) but no concomitant lesions received physical therapy that emphasized early mobilization of the operated shoulder a mean of 10 visits by 6 weeks after surgery. Investigators measured passive shoulder ROM at 6 weeks and compared these measurements to those of the noninvolved limb.
At 6 weeks, mean values for passive flexion, abduction, and external and internal rotation (in 90° of abduction) of the operated shoulder approached those of the noninvolved shoulder: 154°, 138°, 74°, and 39°, respectively, in the operated shoulder compared to 156°, 164°, 91°, and 48°, respectively, in the noninvolved shoulder. Preoperative ROM was not reported in this study, nor were subjects divided into subgroups based on the size of the tear. However, the authors suggested that knowledge of short-term, objective measures of ROM and strength can assist a therapist in the clinical decision-making process, such as when to place more or less emphasis on restoring ROM or strength during a rehabilitation program. The ROM results of this study also demonstrate the value of early postoperative mobilization and to what extent return of shoulder mobility is possible just 6 weeks after mini-open rotator cuff repair.
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Goals and interventions. The following goals and interventions are appropriate during this phase of rehabilitation.8,25,39,56,58,62,128
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PRECAUTION: The use of passive stretching and grade III joint mobilizations, if initiated during this phase of rehabilitation, must be done very cautiously. Vigorous stretching is not considered safe for 3 to 4 months, the time needed for the repaired tendons to have healed and become reasonably strong.128
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CLINICAL TIP
Because weakness and atrophy of the rotator cuff often are present prior to injury, strengthen and increase endurance of the cuff muscles before dynamically strengthening the shoulder abductors and flexors.
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Criteria to progress. Criteria to transition to the final phase of rehabilitation and gradually return to unrestricted activities include:
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Exercise: Minimum Protection/Return to Function Phase
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This final phase usually begins no earlier than 12 to 16 weeks postoperatively for patients with strong repairs or at 16 weeks or later for a tenuous repair. This phase may continue 6 months or more depending on the patient's expected functions during activities.
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Goals and interventions. The goals and interventions during this final phase of rehabilitation are consistent with those previously discussed for late-stage nonoperative management of cuff disorders and for the final phase of rehabilitation after subacromial decompression. However, the progression of activities after a cuff repair is more gradual, and the time frame for adhering to precautions is more extended.
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If full ROM still has not been restored by the beginning of this phase, include passive stretching of the GH musculature and joint mobilization. Incorporate activities that move the arm into the increased ranges of motion, such as gently swinging a golf club or tennis racket if the motions are pain-free. Advanced, task-specific strengthening activities dominate this phase of rehabilitation.
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Patients generally are not allowed to return to high-demand activities for 6 months to 1 year postoperatively, depending on the patient's level of comfort, strength, and flexibility as well as the demands of the desired activities.
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Outcomes
A considerable number of outcome studies of operative management of rotator cuff tears have been reported in the literature with follow-up ranging from less than 6 months to 5 years or more. Outcomes commonly measured include pain relief, shoulder ROM and strength, overall function, and patient satisfaction.
Long-term outcomes after fully arthroscopic, mini-open, and traditional open repairs are comparable.79 For example, after fully arthroscopic repair of full-thickness tears (mostly small or medium but some large or massive tears), overall outcomes of several studies were reported as good to excellent in 84%66,67 and 92%195 of patients followed for 2 to 3 years. These results are comparable to results reported for open repairs.79,128 However, it has been shown that regardless of the type of operative repair performed, the size of the cuff tear influences postoperative outcomes. For example, comparably favorable long-term functional outcomes and pain relief have been reported after mini-open and traditional open repairs of small to medium-sized, full-thickness tears,9,79,128 while outcomes are less favorable after repairs of large or massive tears.128,217
Other factors, such as the acuity or chronicity of the tear and the patient's age, also affect outcomes. Repairs of acute tears in young patients are more successful than repairs of similar-size tears associated with chronic cuff impingement and insufficiency in elderly patients (>65 years).75 The presence of fewer associated pathologies, such as a biceps tendon tear or cuff tear arthropathy, also are associated with better postoperative outcomes.128
Pain relief. Although the results of individual studies vary, a systematic review of the literature indicated that an average of 85% of patients who have operative repair of the rotator cuff report satisfactory relief of pain. Pain relief after arthroscopic and mini-open repairs ranges between 80% and 92%.178 This is comparable to results of previous studies of traditional open repairs, in which satisfactory pain relief was reported by 85% to 95% of patients.78,87 The preoperative size of the tear has an impact on pain relief; specifically, patients with small and medium tears report a higher percentage of satisfaction with pain relief than patients with large or massive lesions.78,128,178
Shoulder ROM. In a prospective descriptive study of patients undergoing rotator cuff repair, the preoperative factor that most closely correlated with long-term limitation of shoulder ROM after surgery was the inability to place the hand behind the back.207 Postoperative shoulder ROM is also associated with the size of the tear, with one study demonstrating that patients who had repairs of small to medium tears had more active flexion and abduction than patients with large tears.87
Strength. The rate of recovery of shoulder muscle strength also appears to be associated with the size of the tear, with faster recovery occurring with repair of small and medium tears than with repair of large or massive tears. Near-complete restoration of shoulder muscle strength occurs gradually and may take a year after repair of small and medium tears, while recovery of strength after repair of large or massive tears is inconsistent.128,178 Although recovery of shoulder muscle strength occurs gradually throughout the first postoperative year, the most substantial gains are seen during the first 6 months.128 In most cases, patients achieve 80% strength in the operated shoulder (compared to the noninvolved shoulder) by 6 months and 90% by 1 year.173
Functional abilities. It has been suggested that long-term functional outcomes correlate with the size of the tear, type of repair, tissue quality, and the integrity of the repair.128 For example, patients who have undergone a mini-open repair return to functional activities about a month earlier than those who have had an open repair.9 However, this outcome may be skewed by the fact that mini-open repairs are performed more often in younger patients with less severe tears.
Lastly, in a study of patients who presented with recurrence of a rotator cuff tear after repair, 80% of the patients had been reported to have good to excellent short-term functional outcomes, measured by objective criteria. This suggests that the evidence regarding whether there is a direct relationship between the integrity of the repair and the functional outcome is inconsistent.78
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Shoulder Instabilities: Nonoperative Management
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Related Pathologies and Mechanisms of Injury
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Glenohumeral joint hypermobility can be atraumatic or traumatic. Atraumatic hypermobility, often referred to as instability, can be due to generalized connective tissue laxity or from microtrauma related to repetitive activities. Traumatic instability is caused by a single or sequence of high force events that compromise the integrity of the stabilizing structures, often dislocating the GH joint. With traumatic dislocation, there is complete separation of the articular surfaces of the GH joint from direct or indirect forces applied to the shoulder.156 Atraumatic instability may be a predisposing factor to traumatic dislocation, especially with repetitive stressful overhead activities.89 GH joint hypermobility, regardless of whether atraumatic or traumatic, is often categorized as unidirectional or multidirectional. A secondary effect of hypermobility is an impingement syndrome (described in an earlier section).
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Atraumatic Hypermobility
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Unidirectional instability. Unidirectional instability can be anterior, posterior, or inferior and is named for the direction that the joint is compromised. It may be the result of physiological laxity of the connective tissues or repetitive nonuniform loading of the joint. With the compromise of stabilizing structures, the humeral head may continue to dislocate or sublux in the direction of the instability. This can lead to progressive degeneration of tissues and eventually tears in the supporting structures.
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Anterior instability usually occurs with forces against the arm when it is in an abducted and externally rotated position, resulting in anterior humeral head translations. If these forces occur with enough frequency and force to compromise anterior GH joint structures, instability results. Often these forces are self-generated, as in throwing athletes who repetitively position the arm such that the anterior capsule is overloaded. Positive signs include apprehension, load and shift, and anterior drawer tests.123,226
Posterior instability is much less common but can occur from repetitive forces against a forward-flexed humerus, translating the humeral head posteriorly. There is a positive posterior drawer sign.123,226
Inferior instability is typically the result of rotator cuff weakness/paralysis and is frequently seen in patients with hemiplegia.72 It is also prevalent in patients who repetitively reach overhead (workers or swimmers, for example) and those with multidirectional instability. This is detected with a positive sulcus sign.123,226
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Multidirectional instability. The GH joint is considered to have multidirectional instability when stability is compromised in more than one direction. Some individuals have physiologically increased extensibility of connective tissue, causing excessive joint mobility. In the GH joint, this increased extensibility allows larger than normal humeral head translations in all directions.156,181 Many individuals, particularly those involved in overhead activities, develop laxity of the capsule from continually subjecting the joint to stretch forces.65,98 Multidirectional instability is confirmed by a combination of the positive tests noted previously for unidirectional instability.
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Common Structural and Functional Impairments
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With atraumatic instability, symptoms are often chronic, intermittent, and activity dependent. Acute symptoms are infrequent but may occur if there is a significantly increased demand placed on the joint. Decreased endurance of the rotator cuff muscles may be a precipitating factor of repetitive trauma of the joint.
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Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
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Possibility of recurrence when replicating the dislocating position or with forces applied to the arm in the dislocating position
With anterior instability, restricted ability in sports activities, such as pitching, swimming, serving (tennis, volleyball), spiking (volleyball)
With posterior dislocation, restricted ability in sports activities, such as follow-through in pitching and golf; restricted ability in pushing activities, such as pushing open a heavy door or pushing one's self up out of a chair or out of a swimming pool
Discomfort or pain when sleeping on the involved side
Inability to maintain arm positions or complete tasks requiring prolonged effort, especially overhead tasks
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Traumatic Hypermobility
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Traumatic anterior shoulder dislocation. Anterior dislocation most frequently occurs when there is a posteriorly directed force to the arm while the humerus is in a position of elevation, external rotation, and horizontal abduction. In that position, stability is provided by the subscapularis, GH ligaments (particularly the anterior band of the inferior ligament), and long head of the biceps.109,172,208 A significant force to the arm may damage these structures, along with the attachment of the anterior capsule and glenoid labrum (Bankart lesion depicted in Fig. 17.19).
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Traumatic anterior dislocation is usually associated with complete rupture of the rotator cuff. There may also be a compression fracture at the posterolateral margin of the humeral head (Hill-Sachs lesion also depicted in Fig. 17.19). Neurological or vascular injuries may also occur during dislocations.76 The axillary nerve is most commonly injured, but the brachial plexus or one of the peripheral nerves could be stretched or compressed.
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Traumatic posterior shoulder dislocation. Traumatic posterior shoulder dislocation is less common. The mechanism of injury is usually a force applied to the arm when the humerus is positioned in flexion, adduction, and internal rotation, such as falling on an outstretched arm.164 The person complains of symptoms when doing activities such as push-ups, a bench press, or follow-through on a golf swing.76
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Recurrent Dislocations
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With significant ligamentous and capsular laxity, unidirectional or multidirectional recurrent subluxations or dislocations may occur with any movement that reproduces the humerus positions and forces that caused the original instability, causing significant pain and functional limitation. Some individuals can voluntarily dislocate the shoulder anteriorly or posteriorly without apprehension and with minimal discomfort.156,185 The rate of recurrence after the first traumatic dislocation is highest in the younger population (< 30 years). Because they are more active and place greater demands on the shoulder, longer immobilization (> 3 weeks) is advocated after dislocation than in the less than 30-year-old patient. Shorter immobilization (1 to 2 weeks) is advocated for older patients.127,130
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Common Structural and Functional Impairments
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After an acute traumatic injury, symptoms resulting from tissue damage include pain and muscle guarding due to bleeding and inflammation.
When a dislocation is associated with a complete rotator cuff tear, there is an inability to abduct the humerus against gravity, except the range provided by the scapulothoracic muscles.
Asymmetrical joint restriction/hypermobility. With anterior instability, the posterior capsule may become tight; with posterior instability, the anterior capsule may become tight. After healing from a traumatic event, there may be capsular adhesions.
With recurrent dislocations, the individual can dislocate the shoulder at will, or the shoulder may dislocate during specific activities.
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Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
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With rotator cuff rupture, inability to reach or lift objects to the level of horizontal, thus interfering with all activities using humeral elevation
Possibility of recurrence when replicating the dislocating position or with forces applied to the arm in the dislocating position
With anterior dislocation, restricted ability in sports activities, such as pitching, swimming, serving (tennis, volleyball), spiking (volleyball)
Restricted ability, particularly when overhead or horizontal abduction movements are required while dressing, such as putting on a shirt or jacket, and with self-grooming, such as combing the back of the hair
Discomfort or pain when sleeping on the involved side in some cases
With posterior dislocation, restricted ability in sports activities, such as follow-through in pitching and golf; restricted ability in pushing activities, such as pushing open a heavy door or pushing one's self up from a chair or out of a swimming pool
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Closed Reduction of Anterior Dislocation
+
++
NOTE: Reduction manipulations should be undertaken only by someone specially trained in the maneuver because of the vulnerability of the brachial plexus and axillary blood vessels.
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Management: Protection Phase
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Protect the Healing Tissue
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Activity restriction is recommended for 6 to 8 weeks in a young patient. If a sling is used, the arm is removed from the sling only for controlled exercise. During the first week, the patient's arm may be continuously immobilized because of pain and muscle guarding.
An older, less active patient (> 40 years of age) may require immobilization for only 2 weeks.
The position of dislocation must be avoided when exercising, dressing, or doing other daily activities.
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FOCUS ON EVIDENCE
Traditionally, after acute anterior shoulder dislocation, immobilization (for various lengths of time) has been instituted. A clinical commentary that looked at outcomes from various studies found that the literature does not support the use of a traditional sling for immobilizing the shoulder following primary anterior shoulder dislocation.89 Still, it was noted that reports showed significantly better results (relative to redislocation) with activity restriction for 6 to 8 weeks in those < 30 years of age compared to activity restriction of less than 6 weeks.
The commentary also summarized two studies that looked at joint positioning during immobilization (magnetic resonance imaging with 18 patients and a cadavaric study). The study supported positioning the humerus in adduction and external rotation (rather than internal rotation) for better approximation between the detached glenoid labrum (Bankart lesion) and the glenoid neck.
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Promote Tissue Health
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Protected ROM, intermittent muscle setting of the rotator cuff, deltoid, and biceps brachii muscles, and grade II joint mobilization techniques (with the humerus at the side or in the resting position) are initiated as soon as the patient tolerates them.
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PRECAUTIONS: In order not to disrupt healing of the capsule and other damaged tissues after anterior dislocation, ROM into external rotation is performed with the elbow at the patient's side, with the shoulder flexed in the sagittal plane, and with the shoulder in the resting position (in the plane of the scapula, abducted 55° and 30° to 45° anterior to the frontal plane) but not in the 90° abducted position. The forearm is moved from in front of the trunk (maximal internal rotation) to 0° or possibly 10° to 15° external rotation.
++
CONTRAINDICATION: Extension beyond 0° is contraindicated.
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Management: Controlled Motion Phase
++
The patient continues to protect the joint and delay full return to unrestricted activity. If a sling is being used, the patient increases the time the sling is off. The sling is used when the shoulder is tired or if protection is needed.
+++
Increase Shoulder Mobility
++
Mobilization techniques are initiated using all appropriate glides except the anterior glide. The anterior glide is contraindicated even though external rotation is necessary for functional elevation of the humerus. For a safe stretch to increase external rotation, place the shoulder in the resting position (abducted 55° and horizontally adducted 30°); then externally rotate the humerus to the limit of its range, and apply a grade III distraction force perpendicular to the treatment plane in the glenoid fossa (Fig. 17.20).
The posterior joint structures are passively stretched with horizontal adduction self-stretching techniques.
++
+++
Increase Stability and Strength of Rotator Cuff and Scapular Muscles
++
Both the internal and external rotators need to be strengthened as healing occurs.26 The internal rotators and adductors must be strong to support the anterior capsule. The external rotators must be strong to stabilize the humeral head against anterior translating forces and to participate in the deltoid-rotator cuff force couple when abducting and laterally rotating the humerus. Scapular stability is important for normal shoulder function and to maintain the scapula in normal alignment. The following exercises are initiated.
++
Isometric resistance exercises with the joint positioned at the side and progressed to various pain-free positions within the available ranges.
Partial weight-bearing and stabilization exercises.
Dynamic resistance, limiting external rotation to 50° and avoiding the position of dislocation.
At 3 weeks, supervised isokinetic resistance for internal rotation and adduction at speeds of 180° per second or higher may be used.7 Position the patient standing with the arm at the side or in slight flexion and elbow flexed 90°. The patient performs internal rotation beginning at the zero position with the hand pointing anteriorly and moving across the front of the body.
Progress to positioning the shoulder at 90° flexion. Have the patient perform the exercise from zero to full internal rotation. Do not position in 90° abduction.
By 5 weeks, all shoulder motions are incorporated into exercises on isokinetic or other mechanical equipment except in the position of 90° abduction with external rotation.
+++
Management: Return to Function Phase
+++
Restore Functional Control
++
The following are emphasized.
++
A balance in strength of all shoulder and scapular muscles
Coordinated scapulothoracic and arm motions
Endurance for each previously described shoulder instability exercise
++
As stability improves, progress to:
++
Eccentric training to maximum load.
Increasing speed and control of combined motions.
Simulating desired functional patterns for activity.
+++
Return to Full Activity
++
The patient can return to normal activities when there is no muscle strength imbalance, good coordination is present during skilled movements, and the apprehension test is negative. Full rehabilitation takes 2.5 to 4 months.7
It is important that the patient learns to recognize signs of fatigue and impingement and is educated about how to reduce the exercise load when these signs are noticed.
+++
Closed Reduction of Posterior Dislocation
++
The management approach is the same as for anterior dislocation with the exception of avoiding the position of humeral flexion with adduction and internal rotation during the acute and healing phases.
++
CLINICAL TIP
Use of a sling following a posterior dislocation may be uncomfortable because of the adducted and internally rotated position of the humerus, particularly if the sling elevates the humerus so the head translates in a superior and posterior direction. The patient may be more comfortable with the arm hanging freely in a dependent position while kept immobile.
++
When mobilization is allowed, begin joint mobilization techniques using all appropriate glides except the posterior glide. Posterior glide is contraindicated. If adhesions develop that limit internal rotation, mobility can be regained safely by placing the shoulder in the resting position (abducted 55° and horizontally adducted 30°), internally rotating it to the limit of its range, and applying a grade III distraction force perpendicular to the treatment plane in the glenoid fossa (same as in Fig. 17.20 but with the arm internally rotated).
+++
Shoulder Instabilities: Surgery and Postoperative Management
++
Surgical stabilization procedures are often necessary to repair chronic, recurrent instabilities and acute traumatic lesions in the glenohumeral, acromioclavicular, and sternoclavicular joints to restore function. Background information on GH joint instabilities and injuries that frequently occur with dislocations to this joint was described in the previous sections on nonoperative management.
+++
Glenohumeral Joint Stabilization Procedures and Postoperative Management
++
If a reasonable trial of nonoperative management has not been successful in preventing recurrence of GH joint instability, surgical stabilization may be considered. Recurrent instability after a traumatic event responds more favorably to surgical management than atraumatic instabilities.14,127 Young, active patients who have sustained an acute, traumatic, anterior dislocation for the first time may elect to undergo surgery without a prior course of rehabilitation, because there is a particularly high rate of recurrence of dislocation in this group after nonoperative management.127,130
++
FOCUS ON EVIDENCE
In a small, prospective, randomized study21 of young athletes who had sustained a first-time, acute, traumatic, anterior shoulder dislocation, one group of patients (n = 14) participated in a nonoperative rehabilitation program of immobilization and exercise and another group (n = 10) underwent arthroscopic stabilization (repair of a Bankart lesion) and postoperative rehabilitation (the same program the nonoperative group followed). Over an average of 36 months, of the 12 nonoperatively managed patients who were available for follow-up, 9 (75%) experienced recurrent instability, whereas of the 9 operatively managed patients available for follow-up, only 1 (11.1%) experienced recurrent instability. Six of the nine nonoperatively treated patients who experienced recurrent instability subsequently had an open Bankart repair.
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In another randomized study107 of young patients (mean age 22 years) who sustained traumatic anterior dislocations, patients either participated in a trial of nonoperative management or underwent immediate arthroscopic stabilization. Over a 2-year period, 47% of the patients in the nonoperative group—but only 15% of the surgical group—experienced recurrence of the dislocation. The results of these studies demonstrate that in young patients, early surgical stabilization followed by postoperative rehabilitation significantly reduces the incidence of recurrent instability compared to nonoperative management.
+++
Indications for Surgery
++
The following are common indications for surgical stabilization of the GH joint.127,130,199,215,219
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Recurrent episodes of GH joint dislocation or subluxation that impair functional activities
Unidirectional or multidirectional instability during active shoulder movements that causes apprehension about placing the arm in positions of potential dislocation, leading to compromised use of the arm for functional activities
Instability-related impingement (secondary impingement syndrome) of the shoulder
Significant inherent joint laxity resulting in recurrent involuntary dislocation
High probability of subsequent episodes of recurrence of dislocation after an acute traumatic dislocation in young patients involved in high-risk (overhead), work-related, or sport activities
Dislocations associated with significant cuff tears or displaced tuberosity or glenoid rim fractures
Irreducible (chronic, fixed) dislocation
Failure to resolve the instability and restore function with nonoperative management.
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Procedures designed to improve stability and prevent recurrent instability of the GH joint must balance stabilization of the joint with retention of near-normal, functional mobility. Stabilization procedures, which may involve the anterior, posterior, or inferior portions of the capsule, are performed today using either an arthroscopic or open approach depending on the type of lesion(s) present and type of procedure selected by the surgeon.127,130,164,194,215 Open stabilization procedures are highly successful (low recurrence of dislocation) and have been considered the standard for years. However, with advances in arthroscopic techniques and methods of tissue fixation, the use and success of arthroscopic stabilization procedures has steadily increased.215
++
Recurrent anterior (unidirectional) dislocation is by far the most common form of GH instability managed with surgical stabilization.130 In contrast, posterior or posteroinferior instabilities are less fequently managed with surgical stabilization.164 The surgical procedures can be organized into several categories.
++
Bankart repair. A Bankart repair involves an open or arthroscopic repair of a Bankart lesion (detachment of the capsulolabral complex from the anterior rim of the glenoid) (see Fig. 17.19), which commonly accompanies a traumatic anterior dislocation. During the repair an anterior capsulolabral reconstruction is performed to reattach the labrum to the surface of the glenoid lip.*
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With an open repair, the humeral insertion of the subscapularis is detached (a takedown) or split longitudinally for access to the lesion and capsule.71,127,175,179 Occasionally, access is achieved through the rotator cuff interval, which allows the subscapularis to remain intact.127 If the subscapularis is detached, it is repaired after the labrum has been reattached. With an arthroscopic approach, multiple portal sites are used, and the subscapularis is not disturbed.5,215 Repair of a Bankart lesion is combined with an anterior capsular shift if capsular redundancy is present.
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With an open procedure, the labrum is reattached with direct transglenoid sutures or suture anchors, whereas with an arthroscopic approach transglenoid sutures, suture anchors, or tacks are used.89,215 Generally, more secure fixation is achieved with an open repair than with an arthroscopic repair, although in recent years advances in arthroscopic tissue fixation have improved.215
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Capsulorrhaphy (capsular shift). Capsulorrhaphy, which can be performed using either an open or arthroscopic approach, involves tightening the capsule to reduce capsular redundancy and overall capsule volume by incising, overlapping in a pants-and-vest manner (imbrication), and then securing the lax or overstretched portion of the capsule (plication) with direct sutures, suture anchors, tacks, or staples.†
++
A capsular shift procedure is tailored to the direction(s) of instability: anterior, inferior, posterior, or multidirectional (anteroinferior or posteroinferior). For example, if a patient has recurrent anteroinferior (multidirectional) instability, an anterior or inferior capsular shift is performed in which the anterior or inferior portion of the capsule is incised, tightened by imbrication (plication), and resutured. Most capsular shift procedures are performed because of anterior instability.13,127,130,233
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Electrothermally assisted capsulorrhaphy. Electrothermally assisted capsulorrhaphy (ETAC) involves an arthroscopic approach that uses thermal energy (radiofrequency thermal delivery or nonablative laser) to shrink and tighten loose capsuloligamentous structures. The procedure—also referred to as a thermal-assisted capsular shift (TACS) or thermocapsular shrinkage—can be used alone but more often is used in conjunction with other arthroscopic procedures, such as repair of a glenoid tear, a capsular shift, débridement of a partial rotator cuff tear, or subacromial decompression.‡
++
It has been shown in animal and human cadaveric studies that thermal energy initially makes collagen fibrils more extensible; but as the collagen tissue of the capsuloligamentous structures heals, it shortens or "shrinks," causing a decrease in capsular laxity.88,186 If one or more of the glenohumeral ligaments is detached or if rotator cuff lesions that could be contributing to the instability are detected, they are repaired arthroscopically prior to ETAC.
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Posterior capsulorrhaphy (posterior or posteroinferior capsular shift). Recurrent, involuntary posterior or posteroinferior instability (far less common than anterior instability), if treated surgically, can be managed with either an open or arthroscopic capsular shift to remove posterior and inferior redundancy of the capsule.* Additional soft tissue procedures, such as repair of a posterior labral tear (reverse Bankart lesion) or in rare instances plication and advancement of the infraspinatus to reinforce the posterior capsule, may be necessary. Shoulders without an effective posterior glenoid can be surgically managed with capsulolabral augmentation215 or occasionally with a glenoid osteotomy.127,164
++
Employing arthroscopic posterior stabilization, a capsular shift and repair of the posterior labrum can be accomplished with the shoulder musculature remaining intact.163 For an open stabilization, a posterolateral incision is made; the deltoid is split; and the infraspinatus, teres minor, and posterior capsule are incised.164,200 In some instances of traumatic multidirectional instability, anterior capsulorrhaphy is used to tighten the posterior capsule indirectly.127,164,215
++
Repair of a SLAP lesion. A tear of the superior labrum is classified as a SLAP lesion (superior labrum extending anterior to posterior).50,199,215,231 Some SLAP lesions are associated with a tear of the proximal attachment of the long head of the biceps tendon and recurrent anterior instability of the GH joint. An arthroscopic repair involves débridement of the torn portion of the superior labrum, abrasion of the boney surface of the superior glenoid, and reattachment of the labrum and biceps tendon with tacks or suture anchors. Concomitant anterior stabilization is also performed if instability is present.
+++
Postoperative Management
+++
General Considerations
++
As with rehabilitation after repair of rotator cuff tears, guidelines for postoperative management after surgical stabilization of the GH joint are based on many factors. These factors, all of which can influence the composition and progression of a postoperative program, are summarized in Table 17.6. Additional factors, such as the philosophy and training of the surgeon and a number of patient-related variables (general health, medications, preinjury functional status and postoperative goals, education, compliance) that affect rehabilitation after GH stabilization and rotator cuff repair already have been addressed (see Table 17.4).
++
++
The content in this section identifies general principles of management across three broad phases of postoperative rehabilitation after a variety of surgical stabilization and reconstruction procedures for recurrent unidirectional or multidirectional instabilities of the GH joint. These general guidelines cannot begin to address the many variations of rehabilitation programs recommended for specific stabilization procedures. However, many detailed protocols or case-based descriptions of rehabilitation programs for use after specific procedures and for specific types of shoulder instabilities and associated labral or rotator cuff lesions in various patient populations are available in the literature.*
++
Regardless of the type of instability, associated pathology, or type of surgical stabilization procedure, a postoperative rehabilitation program must be based on the findings of a comprehensive examination and individualized to meet the unique needs of each patient. The focus of postoperative rehabilitation is to restore pain-free shoulder mobility and muscular strength and endurance, particularly the dynamic joint stabilizers, to meet the patient's functional needs while preventing recurrence of shoulder instability.
++
Position. The position in which the patient's shoulder is immobilized after surgery is determined by the direction(s) of instability prior to surgery. After surgical reconstruction for recurrent anterior or anteroinferior instability, the shoulder is immobilized in a sling or splint in adduction (arm at the side) or varying degrees of abduction and in internal rotation (forearm across the abdomen) with the arm slightly anterior to the frontal plane of the body.96,127 After surgery for posterior or posteroinferior instability, the upper extremity is supported in an orthosis, and the shoulder is immobilized in the "handshake" position (neutral rotation to 10° to 20° of external rotation, 20° to 30° of abduction, elbow flexed, and arm at the side or sometimes with the shoulder in slight extension).60,127,164
++
Duration. The duration of immobilization—that is, the period of time before use of the immobilizer is completely discontinued—is determined by many factors, including the type of instability, the procedure(s) performed, and the surgeon's intraoperative assessment. This period can range from 1 to 3 weeks to as long as 6 to 8 weeks. However, the period of continuous immobilization of the operated shoulder (before shoulder motion can be initiated) is kept as short as possible but varies with the type of procedure. For example, after an anterior stabilization procedure, the immobilizer may need to be worn continuously for only a day to a few days but in some cases up to 1 to 2 weeks.130 In contrast, repairs of posterior or multidirectional instabilities, which are associated with a higher recurrence of dislocation, usually require a longer period of immobilization.127,164,200 After a posterior stabilization procedure, the shoulder may be continuously immobilized and ROM delayed for up to 6 weeks postoperatively.102,164
++
Time frames for immobilization also vary based on the factors that influence all aspects of postoperative rehabilitation (see Table 17.5). For example, the duration of immobilization is usually shorter for an elderly patient than for a young patient, because the elderly patient is more likely to develop postoperative shoulder stiffness than the young patient. In contrast, a patient with generalized hyperelasticity or a younger patient involved in high-demand activities, who is likely to place excessive stresses on healing tissues, requires a longer period of immobilization to reduce the risk of redislocation.127
++
As with the position and duration of immobilization, the decisions of when the arm may be temporarily removed from the immobilizer to begin shoulder exercises and to what extent specific shoulder motions are either permissible or must be limited are also based on many of the factors previously summarized (see Table 17.6).
++
CLINICAL TIP
During the early weeks of rehabilitation after a surgical stabilization procedure, determining what ranges fall within "safe" limits of motion is based on the extent of intraoperative ROM that was possible without placing excessive tension on the repaired, tightened, or reconstructed tissues. This information may be available in the operative report or should be communicated by the surgeon to the therapist prior to initiating postoperative exercises.
++
Rehabilitation after anterior stabilization (anterior capsular shift or Bankart repair) is similar after open and arthroscopic procedures. In both instances, there are precautions that must be heeded, particularly during the first 6 weeks after surgery while soft tissues are healing. During this time period after an open procedure, the anterior capsule and the detached and repaired subscapularis must be protected from excessive stresses. With an arthroscopic anterior stabilization, although the subscapularis remains intact, it is also necessary to protect the anterior capsule fixation during the initial phase of rehabilitation, because soft tissue fixation may not be as secure as the fixation used in an open procedure.
++
FOCUS ON EVIDENCE
In a 4-year follow-up study by Sachs and colleagues179 of 30 patients who had sustained a traumatic anterior dislocation and had undergone an open Bankart repair (that included takedown and repair of the subscapularis tendon), only postoperative subscapularis function was significantly correlated with the patients' perception of a successful outcome after surgery. Although only two patients (6.7%) reported recurrence of instability over the 4-year period, postoperative testing indicated that seven patients (23%) had incompetence of the subscapularis muscle. Specifically, the mean strength of the subscapularis in these patients was only 27%, whereas in the remaining patients, said to have a competently functioning subscapularis, the mean strength was 80% of the noninvolved shoulder. There was no significant loss of strength in other shoulder muscles in either group of patients.
Of the patients with a reasonably strong subscapularis at the 4-year follow-up, 91% reported good to excellent results, and 100% indicated that they would have the surgery again. However, among the patients with a substantially weak subscapularis, 57% reported good to excellent results, but only 57% would undergo the surgery again. The investigators suggested that the handling of the subscapularis tendon during the repair and protection of the subscapularis the first few weeks following surgery was critical to shoulder function and the patients' perceptions of successful outcomes.
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Precautions after arthroscopic or open anterior stabilization or reconstruction procedures are summarized in Box 17.11.39,71,89,102,127,130,151,215 Precautions for thermally assisted capsular tightening,57,61,167,209,230 posterior stabilization procedures,60,102,163,164 and repair of a SLAP lesion39,50,231 are noted in Box 17.12.
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BOX 17.11 Precautions After Anterior Glenohumeral Stabilization and/or Bankart Repair*
Limit ER, horizontal abduction, and extension (shoulder positions that place stress on the anterior capsule) during first 6 weeks postoperatively.
After an arthroscopic stabilization, although the subscapularis is intact, to avoid pull-out of fixation, limit ER to 5° to 10° with the arm in slight abduction or at the side for the first 2 weeks.39 Then, gradually progress to 45° over the next 2 to 4 weeks with the shoulder in greater abduction. With a tenuous stabilization, may need to limit ER to only neutral for the first 4 to 6 postoperative weeks.215
After an open procedure involving subscapularis takedown and repair, limit ER to 0° (no ER past neutral), to no more than 30° to 45° or to the "safe" limits identified during the intraoperative assessment for 4 to 6 weeks.39
Postpone ER combined with full shoulder abduction for at least 6 weeks.89
After an arthroscopic stabilization, progress forward flexion of the shoulder more cautiously than after an open stabilization.
After boney procedures, delay passive or assisted ROM for 6 to 8 weeks to allow time for bone healing.127,130
No vigorous passive stretching to increase end-range ER for 8 to 12 weeks after either arthroscopic or open procedure except for patients with hypoelastic tissue quality.215
When stretching is permissible, avoid positioning the shoulder in abduction and external rotation during grade III joint mobilization procedures.
After procedures with subscapularis detachment and repair, no active or resisted IR for 4 to 6 weeks; avoid lifting objects, especially if pushing the hands together is required.39,71,89,151
Avoid activities involving positions that place stress on the anterior aspect of the capsule for about 4 to 6 weeks.
Avoid functional activities that require ER, especially if combined with horizontal abduction during early rehabilitation as when reaching to put on a coat or shirt.
Avoid upper extremity weight bearing particularly if the shoulder is extended, as when pushing up from the armrests of a chair.
When dynamically strengthening the rotator cuff, maintain the shoulder in about 45°, rather than 90°, of abduction.
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Exercise: Maximum Protection Phase
++
The initial phase of rehabilitation extends for about 6 weeks after surgery during which time protection of the tightened capsule or repaired or reconstructed structures, such as the labrum or the subscapularis, is necessary while minimizing the negative consequences of immobilization. Exercises may be initiated the day after surgery for select patients who have had an anterior stabilization procedure,39 but more often are begun 1 to 2 weeks postoperatively.102,151 ROM is delayed for a longer period of time after a thermally assisted stabilization,57,61,167,209,230 a posterior stabilization procedure,60,102,163,164 or repair of a SLAP lesion and torn biceps tendon39,50,231 (see Box 17.12).
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BOX 17.12 Precautions After Selected Glenohumeral Stabilization Procedures Thermally Assisted Capsular Tightening
Be extremely cautious with ROM exercises for the first 4 to 6 weeks postoperatively because collagen in the thermally treated capsuloligamentous structures is initially more extensible (more vulnerable to stretch) until it heals. Some patients may begin ROM within protected ranges the day after surgery, whereas others may be required to postpone ROM exercises entirely for 2 weeks or more.
While sleeping, complete immobilization (sling and swathe) for 2 weeks or more.
Precautions for ROM depend on the direction of instability, patient's tissue quality (hyper- or hypoelastic), and the extent of concomitant surgical procedures necessary. For example, progress patients with congenital hyperelasticity more cautiously than those with hypoelasticity.
Posterior Stabilization Procedure and/or Reverse Bankart Repair Postpone all shoulder exercises or limit elevation of the arm to 90° and IR to neutral or no more than 15° to 20° and horizontal adduction to neutral (up to 6 weeks postoperatively).
Restrict upper extremity weight bearing, particularly when the shoulder is flexed, to avoid stress to the posterior aspect of the capsule, for example during closed-chain scapulothoracic and GH stabilization exercises and functional activities, for at least 6 weeks postoperatively.
Avoid resistance exercises that direct loads and place stress on the posterior capsule, such as bench press exercises and prone push-ups until late in the rehabilitation program, if at all.
Repair of a SLAP Lesion For SLAP lesions where the biceps tendon is detached, progress rehabilitation more cautiously than when the biceps remain intact.
Limit passive or assisted elevation of arm to 60° for the first 2 weeks and to 90° at 3 to 4 weeks postoperatively.
Perform only passive assisted humeral rotation with the shoulder in the plane of the scapula for the first 2 weeks (ER to only neutral or up to 15° and IR to 45°); during weeks 3 to 4, progress ER to 30° and IR to 60°.
Avoid positions that create tension in the biceps, such as elbow extension with shoulder extension (as when reaching behind the back), during the first 4 to 6 weeks postoperatively.
Postpone active contractions of the biceps (elbow flexion with supination of the forearm) for 6 weeks and resisted biceps exercises or lifting and carrying weighted objects until 8 to 12 weeks postoperatively depending on the extent and type of biceps repair; then progress cautiously.
If the mechanism of injury was a fall onto the outstretched hand and arm causing joint compression, progress weight-bearing exercises gradually.
If anterior instability is also present, follow precautions in Box 17.11.
Avoid positions of abduction combined with maximum external rotation, as this places torsion forces on the base of the biceps attachment on the glenoid.
++
Goals and interventions. The goals and exercises for the maximum protection phase are summarized in this section.39,57,60,89,151,228,237
++
Control pain and inflammation.
A sling for comfort when the arm is dependent or for protection when in public areas. While seated, remove the sling (if permissible) and rest the forearm on a table or wide armrest with the shoulder positioned in abduction and neutral rotation to provide support but prevent potential contracture of the subscapularis and other internal rotators of the shoulder.
Cryotherapy and prescribed anti-inflammatory medication
Shoulder relaxation exercises
Prevent or correct posture impairments.
Maintain mobility and control of adjacent regions.
Active ROM of the cervical region, elbow, forearm, wrist, and fingers the day after surgery
Active scapulothoracic movements
++
PRECAUTION: Initially, strengthen the scapular stabilizing muscles in open-chain positions to avoid the need for weight bearing on the operated upper extremity. When weight-bearing activities are initiated, be cautious about the position of the operated shoulder to avoid undue stress to the vulnerable portion of the capsule for about 6 weeks postoperatively.
++
+
++
NOTE: In some cases, dynamic exercises against light resistance are delayed until the intermediate phase of rehabilitation (about 6 to 8 weeks postoperatively), when only moderate protection is necessary.
++
Criteria to progress. Criteria to advance to the second phases of rehabilitation are:39,57,89,102
++
+++
Exercise: Moderate Protection Phase
++
The moderate protection phase of rehabilitation begins around 6 weeks postoperatively and continues until approximately 12 to 16 weeks. The focus is on maintaining joint stability while achieving nearly full active (unassisted) ROM of the shoulder; developing neuromuscular control, strength, and endurance of scapulothoracic and GH musculature; and using the upper extremity through greater ranges for functional activities.
++
Goals and interventions. The goals and interventions for the intermediate phase of rehabilitation are as follows.39,57,89,102,228,237
++
Regain nearly full, pain-free, active ROM of the shoulder.
Continue active ROM with the goal of achieving nearly full ROM by 12 weeks.
Incorporate ROM gains into functional activities.
Stretching and grade III mobilization in positions that do not provoke instability. After an anterior stabilization procedure, pay particular attention to increasing horizontal adduction, as the posterior structures are often tight preoperatively and continue to be tight postoperatively.
Continue to increase strength and endurance of shoulder musculature.
Alternating isometrics against increasing resistance with emphasis on the scapula and rotator cuff musculature.
Dynamic resistance exercises initiated or progressed using weights and elastic resistance with emphasis on scapulothoracic and glenohumeral stabilizers. Begin in mid-range positions, progressing to end-range positions. Emphasize both the concentric and eccentric phases of muscle activation.
Dynamic strengthening in diagonal and simulated functional movement patterns.
Upper extremity ergometry with a portable reciprocal exerciser on a table for muscular endurance. Include forward and backward motions.
Progressive upper extremity weight bearing during strengthening and stabilization exercises.
++
PRECAUTIONS: After anterior stabilization, do not initiate dynamic strengthening of the internal rotators from full external rotation, particularly in the 90° abducted position. When strengthening the shoulder extensors, do not extend posterior to the frontal plane. Similarly, when strengthening the horizontal abductors, do not horizontally abduct posterior to the coronal plane. In addition, maintain the shoulder in neutral rotation during horizontal abduction and adduction. After posterior stabilization, do not initially begin dynamic strengthening of the external rotators from a position of full internal rotation
++
Criteria to progress. Criteria to progress to the final phase of rehabilitation and the focus of exercises are similar to the criteria already identified for the final phase of rehabilitation after rotator cuff repair.
+++
Exercise: Minimum Protection/Return to Function Phase
++
This phase usually begins around 12 weeks postoperatively or as late as 16 weeks, depending on individual characteristics of the patient and the surgical stabilization procedure. Stretching should continue until ROM consistent with functional needs has been attained. Gains in ROM are possible for up to 12 months as collagen tissue continues to remodel. Resistance exercises to improve strength and endurance are progressed to replicate movements involved in functional activities, including positions of provocation of instability. Plyometric training (discussed in Chapter 23) is introduced and gradually progressed, particularly in patients intending to return to high-demand sports or work-related activities. Participation in desired work-related and sports activities often takes up to 6 months postoperatively.
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PRECAUTIONS: Some patients may have permanent restrictions placed on functional activities that involve high-risk movements and that could potentially cause recurrence of the instability. After some anterior stabilization procedures, full external rotation (ER) in 90° of abduction may not be advisable or possible.102
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Outcomes
A successful postoperative outcome involves regaining the ability to participate in desired functional activities without a recurrence of instability of the GH joint. There is a wealth of follow-up studies describing various outcomes after stabilization procedures. However, most of the studies comparing the success of one surgical intervention with that of another are not randomized—understandably so because the surgeon's examination is the basis for determining which procedure is most appropriate and will most likely lead to successful results for each patient.
Although postoperative exercise is consistently described as essential for optimal outcomes after stabilization surgery, no current, randomized studies were identified that compared the effectiveness of postoperative exercise programs after stabilization of the GH joint (method of instruction, content, rate of progression) for this review. As with surgical decisions, most postoperative rehabilitation programs are customized to meet each patient's needs, making comparison of outcomes difficult.
Results of surgery and postoperative rehabilitation are typically reported for specific pathologies, patient populations, and surgical stabilization procedures and are determined by means of a variety of outcome measures. Despite this, some generalizations can be made.
Recurrence of instability. Recurrent instability of traumatic origin responds more favorably to surgical management than atraumatic instability.14,127 In addition, the rate of recurrence of instability is substantially higher in young patients (<30 to 40 years of age) and patients who return to high-demand, work-related activities or competitive overhead sports than less active, older patients (>30 to 40 years of age).127,215
The recurrence of dislocation rates after open and arthroscopic procedures also have been compared. Historically, recurrence rates after arthroscopic stabilization have been higher than after open stabilization.40,127 In a review of studies on anterior stabilization procedures, the mean redislocation rate after open stabilization (Bankart lesion repair) was 11% (range 4% to 23%), but recurrence rates after arthroscopic stabilization were 18% (range 2% to 32%) with transglenoid suture fixation and 17% (range 0% to 30%) with tack fixation.89 In another review of recent studies, the recurrence rates of anterior instability after an arthroscopic Bankart repair ranged from 8% to 17%.215 Decreasing redislocation rates after arthroscopic procedures are attributed to improved arthroscopic techniques. Today, arthroscopic stabilization has been shown in many instances to be equal to open stabilization for patients with unidirectional, anterior instability.40,215,220 However, for multidirectional instabilities, outcomes after arthroscopic stabilization are not yet equal to outcomes after open stabilization.215
Outcomes after stabilization procedures for anterior and posterior instabilities also have been compared. Surgical stabilization of a recurrent, unidirectional anterior instability has yielded more predictable results and lower recurrence rates than stabilization of posterior or multidirectional instabilities.14,127,164,215,233 The average recurrence rate of posterior instability after arthroscopic stabilization has been reported to be particularly high. One source reported a 30% to 40% rate of redislocation,200 and another reported rates as high as 50%.215 In contrast, after anterior stabilization procedures, mean recurrence rates have been reported at 11% and 17% to 18%, respectively, for open and arthroscopic procedures.89
As the preoperative diagnosis has improved and the selection of appropriate candidates for surgery has become better, the recurrence of instability after posterior stabilization has decreased. In a study163 with a mean follow-up of 39.1 months, the recurrence rate of instability after arthroscopic posterior stabilization was only 12.1%. The patients in this study had a mean age of 25 years with a history of involuntary or voluntary dislocation of the GH joint associated with acute traumatic and chronic repetitive microtrauma.
Regarding ETAC as the primary stabilization procedure, Hawkins and colleagues86 reported failure in 37 of 85 patients. Failures were those procedures that resulted in the need for a revision stabilization, recurrent instabilities, or recalcitrant pain and stiffness. The authors noted that, for their practice, ETAC is now reserved primarily for augmentation of plication or other procedures in special circumstances
Shoulder ROM. After anterior stabilization procedures, full ER or horizontal abduction is sometimes not advisable or possible.102 Likewise, some posterior stabilization procedures permanently limit full internal rotation (IR) and, to some extent, overhead elevation of the arm.127
After open anterior stabilization and Bankart repair, which usually requires detachment and repair of the subscapularis, a mean loss of 12° of ER has been reported.69 It has been suggested that there is less loss of shoulder ER after arthroscopic procedures than after open procedures.89 However, in a nonrandomized study that compared open and arthroscopic anterior stabilization procedures, both groups had some loss of ER (mean loss of 9° and 11°, respectively, in the arthroscopic and open groups), but these differences between groups were not significant.40
After open GH stabilization for instability due to repetitive microtrauma, postoperative loss of shoulder ER is the most common reason athletes involved in overhead sports are unable to successfully return to competition. Loss of shoulder rotation is reported to be less after arthroscopic stabilization procedures, thus enabling a greater percentage of these athletes to return to competition.167 Early follow-up of patients who have undergone thermally assisted capsular stabilization is encouraging,61 but long-term outcomes are just becoming available. To date, the largest study of overhead athletes who underwent thermally assisted stabilization followed 130 patients for a mean of 29.3 months. Of these athletes, 113 (87%) returned to competition in a mean of 8.4 months. Although postoperative ROM was not reported, the implication was that the return of ROM after thermally assisted arthroscopic stabilization was sufficient for a high percentage of athletes being able to return to competition.
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Acromioclavicular and Sternoclavicular Joint Stabilization Procedures and Postoperative Management
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Acromioclavicular Joint Stabilization
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A grade III separation, in which the acromioclavicular (AC) and coracoclavicular ligaments are completely ruptured may be surgically reduced and stabilized with a variety of techniques.147,169 Techniques for management of acute dislocations include primary stabilization of the AC joint with Kirschner wires, Steinman pins, screws, or most recently bioabsorbable tacks, sutures, or fiber wires. Other procedures include a muscle-tendon transfer that moves the tip of the coracoid process with the attached tendons of the coracobrachialis and short head of the biceps to the undersurface of the clavicle154 or the Weaver-Dunn procedure, which resects the distal clavicle and transfers the CA ligament from the acromion to the shaft of the distal clavicle.147 Based on a small body of evidence in the literature, it appears the best results are achieved with primary AC and coracoclavicular stabilization procedures. Chronic AC dislocations, which are usually associated with degenerative changes of the AC joint, are most often managed with distal clavicle resection coupled with coracoclavicular stabilization.154,169
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Sternoclavicular Joint Stabilization
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Although most sternoclavicular (SC) dislocations are managed nonoperatively, an acute posterior dislocation of the SC joint that cannot be successfully reduced with a closed maneuver or an SC joint that dislocates recurrently are managed surgically. Surgical reduction of a traumatic anterior dislocation is not recommended.168,234 Surgical options for posterior SC dislocations include open reduction with repair of the stabilizing ligaments or resection of a portion of the medial clavicle and fixation of the remaining clavicle to the first rib or sternum with a soft tissue graft.168,234
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Postoperative Management
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After surgical stabilization of either the AC or SC joint, the shoulder is immobilized for up to 6 weeks.44 Exercise interventions are directed toward functional recovery as healing allows. No muscles provide dynamic stabilization of the AC and SC joints, so scapular and glenohumeral strength must be developed to provide indirect stability.
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During the first few weeks of immobilization, the patient is encouraged to perform active ROM of the wrist and hand. If the elbow is supported on a table, the patient is permitted to perform active ROM of the elbow and forearm. The operated extremity, if supported, may be used for light functional activities, such as holding a utensil or typing, but weight bearing and shoulder ROM are completely prohibited during the first 6 weeks.44
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When the immobilization can be removed, restoration of shoulder and elbow mobility and neuromuscular control of the shoulder girdle are the focus of the exercise program. Shoulder ROM (passive, progressing to assisted ROM), active scapular motions, and light isometrics of the shoulder musculature are initiated. Stabilization exercises, dynamic strengthening of the shoulder and scapula musculature, and stretching to restore full ROM are gradually introduced and progressed, as graduated functional activities are integrated into the rehabilitation program.
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