Should We Delay Range of Motion After a Rotator Cuff Repair Surgery?

Over the last several years, there has been a trend among orthopedic surgeons to delay the start of rehabilitation, specifically range of motion exercises, following rotator cuff repair surgery.

It’s my opinion that this trend started in response to the research that has been reported in the past that show issues with tendon healing rates and a large percentage of rotator cuff repairs are not intact at follow up examination.

For example, I previously discussed the outcomes of arthroscopic rotator repairs and noted that at the one year follow up after surgery, 68% had an intact rotator cuff. 32% had a full thickness tear again.

So physicians did what they tend to do… They started to get more conservative and delayed the start of rehabilitation. I’ve discussed a similar to approach to rehabilitation following total shoulder replacement.

But does delaying the start of range of motion after rotator cuff repair surgery even help improve outcomes?

Does immobilization after rotator cuff repair increase tendon healing?

A systematic review was published in the Archives of Orthopaedic and Trauma Surgery that looked at 3 randomized control trials comparing immediate versus delayed range of motion follow rotator cuff repair surgery.

The authors reported a few findings.

Most importantly, there was no difference in tendon healing rate, showing that early range of motion is safe to perform and not the reason why people may retear.

Range of motion improved earlier in the immediate range of motion group, but was similar at the year mark. This is consistent with many past studies. Again physicians read into this and use this stat to favor delayed range of motion, stating that patients are all the same at 1 year postoperative. However, as we all know, restoring motion is key to the patient’s’ subjective and functional outcomes. Similarly, functional outcomes were achieved sooner in the immediate range of motion group.

Based on this systematic review, I would continue to recommend performing control range of motion following rotator cuff repair surgery as it appears to be safe and effective at restoring motion and function sooner than if we delay rehabilitation.

Learn More About How I Evaluate and Treat the Shoulder

I’m pretty excited to announce I have revised my acclaimed online program teaching you exactly how I evaluate and treat the shoulder to now include a lesson on the arthritic shoulder! If you want to learn more about how I work with rotator cuff repairs, and everything else related to the shoulder, you’re going to want to take my online course.

 

Should We Delay Range of Motion After a Total Shoulder Replacement?

Total shoulder replacement surgery is being performed more and more each year.  Our current patients were more active in sports in their youth, potentially increasing the chances of developing an arthritic shoulder.  They also want to remain active as they age, potentially increasing the likelihood that they want to have a total shoulder arthroplasty surgery to allow them to remain active.

Over the years, the surgical technique for a total shoulder replacement has improved, though I’m not sure our rehabilitation approach has also improved.  If our patients are younger and want to be more active after total shoulder replacement, then perhaps our rehabilitation programs should adjust based on their goals.

Rehabilitation Following Total Shoulder Replacement

Historically, a conservative approach was appropriate for many patients, as their needs and activity goals were less aggressive than many patients today.  It was acceptable to have a moderate loss of range of motion in exchange for less pain in their shoulder.

Many surgeons continue to recommend a conservative approach to the restoration of range of motion following surgery.

It is true that one of the primary goals of the postoperative rehabilitation following total shoulder replacement is to protect the subscapularis.  The subscapularis muscle is taken down to some extent during the surgical procedure and the integrity of this muscle has been correlated to the overall outcome of the procedure.

Other motions, such as behind the back and shoulder extension behind their body, also place the arthroplasty in a disadvantageous position and can lead to dislocation of the joint.

But even with these precautions, I am still an advocate of early range of motion, especially if you respect these restrictions.

Passive ROM and Active ROM are Not the Same

A recent report was recently published in Journal of Shoulder and Elbow Surgery that may actually be causing some confusion on when to start range of motion.

In the study, the authors compared a group of patients that began range of motion immediately versus a group that delayed 4 weeks.  The authors reported that the immediate range of motion group gained more motion, restored it earlier, and also showed an earlier increase in functional outcome scores.

However, 96% of the patients that delayed range of motion showed healing of the lesser tuberosity osteotomy, while only 82% of the immediate range of motion group showed healing.  Furthermore, functional outcomes scores 3 months and 1 year after surgery were similar between the groups.

This has led to many recommending a delay in range of motion.  But…

When looking deeper at the methods, the authors chose to use the rope and pulley and stick elevation range of motion exercises.  As we all know, these are not passive range of motion exercises, they are active assisted range of motion exercises.

There’s a big difference between passive and active range of motion exercises!

Previous EMG studies have shown the rotator cuff to be between 18-25% active and the deltoid to be between 21-43% active during these exercises.  Not very passive.  Conversely, passive range of motion exercises have been shown to be between 3-10% active.

This is a big difference.  I believe passive range of motion is appropriate, as long as you respect the restrictions on restoring external rotation to protect the subscapularis and avoid behind the body and behind the back motions to protect the replacement.
Immediate Range of Motion Restores Function Faster

Since we all work with these patients after surgery, we know that they are always happier when they restore their motion sooner.  And this increase in range of motion is likely related to the earlier improvement in functional outcome scores.

I think there is a middle ground of immediate, yet cautious, passive range of motion.  Again, I want to reiterate, “passive” range of motion.  Not active.

By focusing on this, I believe our patients will have much better outcomes.

Learn More About How I Evaluate and Treat the Shoulder

I’m pretty excited to announce I have revised my acclaimed online program teaching you exactly how I evaluate and treat the shoulder to now include a lesson on the arthritic shoulder!  If you want to learn more about how I work with the arthritic shoulder, patients following total and reverse shoulder replacements, and everything else related to the shoulder, you’re going to want to take my online course.

 

Dry Needling for Scapular Winging

This week’s article is a guest post from Michael Infantino.  Michael reached out to me on Facebook and sent me the below videos of a patient’s improvement in scapular winging after dry needling the serratus anterior.

I wanted to share the below article that Michael wrote showing the videos, but also talk about how trigger points may be involved.

I’m not sure what to make of these videos, if trigger points are involved, or exactly how dry needling the serratus anterior helped this patient’s winging.  But I am sure that I was impressed with the results.  I wish we knew more about the reasoning and mechanism, but in the meantime I’m happy we can help people feel and move better.

Dry Needling for Scapular Winging

Can we correct scapular winging in a matter of minutes?  This obviously depends on the cause of the scapular winging.

It is well documented that injury to the long thoracic nerve or cervical spine may lead to medial border scapular winging or dyskinesia of the scapula (Meininger, 2011). These are always challenging.  Ruling out neuromuscular cause can be done with a nerve conduction velocity test or EMG.  

But a recent patient of mine, made me think…

Research has continually shown that muscles with trigger points demonstrate the following:

  • Altered muscle activation patterns on EMG (Lucas, 2010; Wadsworth, 1997)
  • Reduced muscle strength (Celik, 2011)
  • Accelerated muscle fatigue (Ge, 2012)
  • Reduced antagonist muscle inhibition (Ibarra, 2011)  
  • Increased number of trigger points on the painful side (Alburquerque-Sendin, 2013; Bron, 2011; Fernandez-de-las-Penas, 2012; Ge, 2006; Ge, 2008)

Appreciating these findings would lead most to conclude that treatment of trigger points could improve scapular mobility and timing. This was my immediate thought when I noticed a significant medial border scapular winging while watching my patient raise and lower his arm.

It wasn’t until I read this research that I began using dry needling to do more than just manage pain. The results seen following dry needling to the serratus anterior were remarkable.

After seeing this amount of scapular winging, I dry needled his serratus anterior muscle.  Note the remarkable improvement:

How Trigger Point Dry Needling May Impact Scapular Winging

It is well documented that appropriate muscle activation patterns (MAP) surrounding the shoulder is necessary for efficient and pain free mobility (Lucas, 2003). Lucas and group actually gauged the effect of trigger point dry needling on MAP in subjects with latent trigger points (LTrP).

“Latent myofascial trigger points (LTrPs) are pain free neuromuscular lesions that are associated with muscle overload and decreased contractile efficiency” (Simons et al., 1999, p. 12). MAP’s of the upper trapezius, serratus anterior, lower trapezius, infraspinatous and middle deltoid were compared in a group with LTrP’s and one without. Following surface EMG, the LTrP’s were treated with trigger point dry needling. Surface EMG was performed after treatment as well.

Findings from this study were as follows:

  • Muscle activation of the upper trapezius in the LTrP group pre-treatment.
  • Early activation of the infraspinatous in the LTrP group pre-treatment.
  • Increased variability of muscle activation in all muscles assessed in the LTrP group pre-treatment compared to the control group.  
  • Altered MAP of distal musculature (infraspinatous and middle deltoid) were consistent with co-contraction, a finding that has been attributed to increased muscle fatigability (Chabran et al., 2002).
  • Improved muscle activation times in the LTrP group following dry needling.
  • Significant decrease in the variability of muscle activation in the LTrP group following dry needling, except for the serratus anterior.
  • The serratus anterior and lower trapezius showed increased variability in both the control and LTrP group, which may be why the results did not reach significance. This is also consistent with the latest research in JOSPT that found dyskinesia to be normal in asymptomatic populations. (Plummer, 2017).

Based on the both my clinical experiences and the research presented in this paper, it would seem highly valuable to focus on the treatment of trigger points to restore muscle activation patterns surrounding the shoulder complex.

Being able to press the “reset button” on a muscle is important for re-establishing normal muscle activation patterns prior to exercise. Inclusion of other manual therapy and exercise techniques is important for optimizing function of the local musculature (range of motion, hypertrophy, strength and endurance).

No research that I am familiar with has compared dry needling to other manual therapy techniques for restoring MAP in muscles adjacent to the shoulder. Future research that compares various trigger point treatments for restoration of normal MAP would be beneficial.

 

About the Author

Dr. Michael Infantino, DPT, is a physical therapist who works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

References

  • Alburquerque-Sendin, F., Camargo, P.R., Vieira, A., Salvini, T.F., 2013. Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study. Clin. J. Pain 29 (6), 478e486.
  • Bron, C., de Gast, A., Dommerholt, J., Stegenga, B., Wensing, M., Oostendorp, R.A., 2011a. Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC Med. 9, 8.
  • Chabran, E., Maton, B., Fourment, A., 2002. Effects of postural muscle fatigue on the relation between segmental posture and movement. Journal of Electromyography and Kinesiology 12, 67–79.
  • Celik, D., Yeldan, I., 2011. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study. J. Back Musculoskelet. Rehabil. 24 (4), 251e256.
  • Cummings, T.M., White, A.R., 2001. Needling therapies in the management if myofascial trigger point pain: a systematic review. Archives of Physical and Medicine and Rehabilitation 82, 986–992.
  • Ge, H.Y., Arendt-Nielsen, L., Madeleine, P., 2012. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Med. 13 (7), 957e964.
  • Ge, H.Y., Fernandez-de-las-Penas, C., Arendt-Nielsen, L., 2006. Sympathetic facilitation of hyperalgesia evoked from myofas- cial tender and trigger points in patients with unilateral shoul- der pain. Clin. Neurophysiol. 117 (7), 1545e1550.
  • Ge, H.Y., Fernandez-de-Las-Penas, C., Madeleine, P., Arendt- Nielsen, L., 2008. Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle. Eur. J. Pain 12 (7), 859e865.
  • Hillary A. Plummer, Jonathan C. Sum, Federico Pozzi, Rini Varghese, Lori A. Michener. Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without Shoulder Pain. J Orthop Sports Phys Ther:1-25.  
  • Ibarra, J.M., Ge, H.Y., Wang, C., Martinez Vizcaino, V., Graven- Nielsen, T., Arendt-Nielsen, L., 2011. Latent myofascial trigger points are associated with an increased antagonistic muscle activity during agonist muscle contraction. J. Pain 12 (12), 1282e1288.
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Meininger, A.K., Figuerres, B.F., & Goldberg, B.A. (2011). Scapular winging: an update. The journal of The American Academy of Orthopaedic Surgeons, 19(8), 453-462.
  • Simons, D.G., Travell, J.G., Simons, L.S., 1999. The Trigger Point Manual, Vol 1, 2nd Edition. Williams and Wilkins, Baltimore, USA.
  • Wadsworth, D.J.S., Bullock-Saxton, J.E., 1997. Recruitment patterns of the scapular rotator muscles in freestyle swimmers with subacromial impingement. International Journal Sports Medicine 18, 618–624.

 

5 Reasons Why I Don’t Use the Sleeper Stretch and Why You Shouldn’t Either

Ah, the sleeper stretch.  Pretty popular right now, huh, especially in baseball players?  Seems like a ton of people are preaching the use of the sleeper stretch and why everyone needs to use it.  It’s so popular now that physicians are asking for it specifically.

I don’t like the sleeper stretch and I rarely use it, in fact I haven’t used it in years.  I don’t think you should use it either.

There, I said it, I felt like I really had the get that off my chest!

Every meeting I go to, I see more and more people talking like the sleeper stretch is the next great king of all exercises.  Then I get up there and say I don’t use it and everyone looks at me like I have two heads!  Call me crazy, but I think we probably shouldn’t be using it as much as we do.

In fact, I actually think it causes more harm than good.

 

5 Reasons Why Shouldn’t Use the Sleeper Stretch

I haven’t used the sleeper stretch in over a decade and have no issues restoring and maintaining shoulder internal rotation in my athletes with safer and more effective techniques.

If you have followed me for some time, you know that I rarely talk in definitive terms, as I always strive to continue to learn and grow.  I know my opinions will change and things aren’t black and white.  However, over the years my stance on NOT using the sleeper stretch has only strengthening.  As I learn more and grow, I actually feel more strongly that we shouldn’t be using this common stretch.

So why don’t I use the sleeper stretch?  There are actually several reasons.

 

It’s Often Performed for the Wrong Reason

The sleeper stretch is most often recommended for people with a loss of shoulder internal rotation.  When a person has a loss of internal rotation, it can be from several reasons, including:

  1. Soft tissue / muscular tightness
  2. Joint capsular tightness
  3. Joint and boney alignment of the glenohumeral joint and scapulothoracic joint
  4. Boney adaptations to repetitive tasks, such as throwing a baseball and other overhead sports

You must assess the true cause of loss of shoulder motion and treat accordingly.

Of the above reasons, you could argue that only joint capsular tightness would be an indication to perform the posterior capsule.  But see my next point below…

Performing the sleeper stretch for the other reasons could lead to more issues, especially in the case of boney adaptations.  The whole concept of glenohumeral internal rotation deficit (GIRD), is often flawed due to a lack of understanding of the normal boney adaptations in overhead athletes.

I can’t tell you how many people think they have GIRD that I evaluate and that they in fact do NOT have GIRD.  Click here to learn more about how I define GIRD.

 

It Stretches the Posterior Capsule

If you have heard me speak at any of my live or online courses, you know that I am not a believer in posterior capsule tightness in overhead athletes.  Maybe it happens, but I have to admit I rarely (if ever) see it.  In fact, I see way more issues with posterior instability.  Please keep in mind I am talking about athletes.  Not older individuals and not people postoperative.  They can absolutely have a tight posterior capsule.

But for athletes, the last thing I want to do is make an already loose athlete looser by stretching a structure that is so thin and weak, yet so important in shoulder stability.

Urayama et al in JSES have shown that stretching the shoulder into internal rotation at 90 degrees of abduction in the scapular plane does not strain the posterior capsule.  However, by performing internal rotation at 90 degrees of abduction in the sagittal plane, like the sleeper stretch position, places significantly more strain on the posterior capsule.

Based on the first two points I’ve made so far, if you have a loss of shoulder internal rotation, you should never blindly assume you have a tight posterior capsule.

Assess, don’t assume.

But be sure you know how to accurately assess the posterior capsule.  Many people perform it incorrectly.  Click here to read how to assess for a tight posterior capsule.

 

It is an Impingement Position

This one cracks me, check out the photos below, if you rotate a photo of the Hawkins-Kennedy impingement test 90 degrees it looks just like a sleeper stretch.  I personally try to avoid recreating provocative special tests as exercises.

sleeper stretch impingement reinold

 

This is a provocative test for a reason, by performing internal rotation in this position, you impinge the rotator cuff and biceps tendon along the coracoacromial arch.  If you actually had a tight posterior capsule, you’d get subsequent translation anteriorly during this stretch and further impingement the structures.

So based on this, even if you have a tight posterior capsule, I wouldn’t use the sleeper stretch.  I would just perform joint mobilizations in a neutral plane.

 

People Often Perform with Poor Technique

So far we’ve essentially said that people often perform the sleeper stretch for the wrong reasons and can end up torquing the wrong structure (the posterior capsule) and irritating more structures (the rotator cuff and biceps tendon).

Even if you have the right person with the right indication, the sleeper stretch is also often performed with poor technique, which can be equally as disadvantageous.

People often roll too far over onto their shoulder or start in the wrong position.  If you are going to perform the sleeper stretch, at least follow my recommendations on the correct way to perform the sleeper stretch.

 

People Get WAY too Aggressive

Despite the above reasons, this may actually be the biggest reason that I don’t use the sleeper stretch – people just get way too aggressive with the stretch.  The whole “more is better” thought process.  Being too aggressive is only going to cause more strain on the posterior capsule and more impingement.  You may actually flare up the shoulder instead of make it better.

I always say, if you have a loss of joint mobility, torquing into that loss of mobility aggressively is only going to make it worse.

 

When the Sleeper Stretch is Appropriate

There are times when the sleeper stretch is probably appropriate.  But it’s not as often as you think and it’s most often not in athletes.  The older individual with adhesive capsulitis or a postoperative stiff shoulder may be good candidates for the sleeper stretch.  But I honestly still don’t use it in these populations.  There are better things to do.

But of course, there are good ways to perform the sleeper stretch and there are bad ways, technique is important.

For more information on some alternatives to the sleeper stretch, check out my article on sleeper stretch alternatives.

 

6 Keys to Shoulder Instability Rehabilitation

Shoulder instability is a common pathology encountered in the orthopedic and sports medicine setting.

But “shoulder instability” itself isn’t that simple to understand.

Would you treat a high school baseball player that feels like their shoulder is loose when throwing the same as a 35 year old that fell on ice onto an outstretched arm and dislocated their shoulder?  They’re both “shoulder instability,” right?

There exists a wide range of symptomatic shoulder instabilities from subtle recurrent subluxations to traumatic dislocations. Nonoperative rehabilitation is commonly utilized for shoulder instability to regain previous functional activities through specific strengthening exercises, dynamic stabilization drills, neuromuscular training, proprioception drills, scapular muscle strengthening program and a gradual return to their desired activities.

I’ve had great success rehabilitating dislocated shoulders and helping people return back to full activities without surgery.  But to truly understand shoulder instability, there are several key factors that you must consider.

 

Key Factors When Designing Rehabilitation Programs for Shoulder Instability

Because there are so many different variations of shoulder instability, it is extremely important to understand several factors that will impact the rehabilitation program.  This will allow us to individualize programs and enhance recovery.

There are 6 main factors that I consider when designing my rehabilitation programs for nonoperative shoulder instability rehabilitation.  I’m going to cover each in detail.

 

Factor #1 – Chronicity of Shoulder Instability

The first factor to consider in the rehabilitation of a patient with shoulder instability is the onset of the pathology.

Pathological shoulder instability may result from an acute, traumatic event or chronic, recurrent instability. The goal of the rehabilitation program may vary greatly based on the onset and mechanism of injury.

Following a traumatic subluxation or dislocation, the patient typically presents with significant tissue trauma, pain and apprehension. The patient who has sustained a dislocation often exhibits more pain due to muscle spasm than a patient who has subluxed their shoulder. Furthermore, a first time episode of dislocation is generally more painful than the repeat event.

Rehabilitation will be progressed based on the patient’s symptoms with emphasis on early controlled range of motion, reduction of muscle spasms and guarding and relief of pain.

The primary traumatic dislocation is most often treated conservatively with immobilization in a sling and early controlled passive range of motion (ROM) exercises especially with first time dislocations. The incidence of recurrent dislocation ranges from 17-96% with a mean of 67% in patient populations between the ages of 21-30 years old. Therefore, the rehabilitation program should progress cautiously in young athletic individuals. It should be noted that Hovelius et al has demonstrated that the rate of recurrent dislocations is based on the patient’s age and not affected by the length of post-injury immobilization. Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability. Hovelius et al also noted patients in their 20’s exhibited a recurrence rate of 60% whereas patients in their 30’s to 40’s had less than a 20% recurrence rate. In adolescents, the recurrence rate is as high as 92% and 100% with an open physes.

Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks.

Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.

Chronic subluxations, as seen in the atraumatic, unstable shoulder may be treated more aggressively due to the lack of acute tissue damage and less muscular guarding and inflammation. Rotator cuff and periscapular strengthening activities should be initiated while ROM exercises are progressed. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.

The goal is to enhance strength, proprioception, dynamic stability and neuromuscular control especially in the specific points of motion or direction which results in instability complaints.

 

Factor #2 – Degree of Shoulder Instability

Bankart LesionThe second factor is the degree of instability present in the patient and its effect on their function.

Varying degrees of shoulder instability exist such as a subtle subluxation or gross instability. The term subluxation refers to the complete separation of the articular surfaces with spontaneous reduction. Conversely, a dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint. This will result in underlying capsular tissue trauma. Thus, with shoulder dislocations the degree of trauma to the glenohumeral joint’s soft tissue is much more extensive.

Speer et al have reported that in order for a shoulder dislocation to occur, a Bankart lesion must be present and also soft tissue trauma must be present on both sides of the glenohumeral joint capsule.

Thus, in the situation of an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid (this is called a Bankart lesion – see pictures to the right) and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept.”

The rate of progression will vary based upon the degree of instability and persistence of symptoms. For example, a patient with mild subluxations and muscle guarding may initially tolerate strengthening exercises and neuromuscular control drills more than a patient with a significant amount of muscular guarding.

 

Factor #3 – Concomitant Pathology

Hill Sachs LesionThe third factor involves considering other tissues that may have been affected and the premorbid status of the tissue.

As we previously discussed, disruption of the anterior capsulolabral complex from the glenoid commonly occurs during a traumatic injury resulting in an anterior Bankart lesion. But other tissues may also be involved.

Often osseous lesions may be present such as a concomitant Hill Sach’s lesion caused by an impaction of the posterolateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation. This has been reported in up to 80% of dislocations. Conversely, a reverse Hill Sach’s lesion may be present on the anterior aspect of the humeral head due to a posterior dislocation.

Occasionally, a bone bruise may be present in individuals who have sustained a shoulder dislocation as well as pathology to the rotator cuff. In rare cases of extreme trauma, the brachial plexus may become involved as well. Other common injuries in the unstable shoulder may involve the superior labrum (SLAP lesion) such as a type V SLAP lesion characterized by a Bankart lesion of the anterior capsule extending into the anterior superior labrum. These concomitant lesions will affect the rehabilitation significantly in order to protect the healing tissue.

 

 

Factor # 4 – Direction of Shoulder Instability

Shoulder Multidirectional InstabilityThe next factor to consider is the direction of shoulder instability present. The three most common forms include anterior, posterior and multidirectional.

Anterior shoulder instability is the most common traumatic type of instability seen in the general orthopedic population. It has been reported that this type of instability represents approximately 95% of all traumatic shoulder instabilities. However, the incidence of posterior instabilities appears to be dependent on the patient population. For example, in professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen. Often, these posterior instability patients require surgery as Mair et al reported 75% required surgical stabilization.

Following a traumatic event in which the humeral head is forced into extremes of abduction and external rotation, or horizontal abduction, the glenolabral complex and capsule may become detached from the glenoid rim resulting in anterior instability, or a Bankart lesion as discussed above.

Conversely, rarely will a patient with atraumatic instability due to capsular redundancy dislocate their shoulder. These individuals are more likely to repeatedly sublux the joint without complete separation of the humerus from the glenoid rim.

Posterior shoulder instability occurs less frequently, only accounting for less than 5% of traumatic shoulder dislocations.

This type of instability is often seen following a traumatic event such as falling onto an outstretched hand or from a pushing mechanism. However, patients with significant atraumatic laxity may complain of posterior instability especially with shoulder elevation, horizontal adduction and excessive internal rotation due to the strain placed on the posterior capsule in these positions.

Multidirectional instability (MDI) can be identified as shoulder instability in more than one plane of motion. Patients with MDI have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule.

Shoulder Sulcus SignOne of the most simple tests you can perform to assess MDI is the sulcus sign.

I would consider an inferior displacement of greater than 8-10mm during the sulcus maneuver with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity.  You can see this pretty good in this photo to the right, the sulcus is clearly larger than my finger width.

Due to the atraumatic mechanism and lack of acute tissue damage with MDI, ROM is often normal to excessive.

Patients with recurrent shoulder instability due to MDI generally have weakness in the rotator cuff, deltoid and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers. Initially, the focus is on maximizing dynamic stability, scapula positioning, proprioception and improving neuromuscular control in mid ROM.

Also, rehabilitation should focus on improving the efficiency and effectiveness of glenohumeral joint force couples through co-contraction exercises, rhythmic stabilization and neuromuscular control drills. Isotonic strengthening exercises for the rotator cuff, deltoid and scapular muscles are also emphasized to enhance dynamic stability.

 

Factor #5 – Neuromuscular Control

neuromuscular controlThe fifth factor to consider is the patient’s level of neuromuscular control, particularly at end range.

Injury with resultant insufficient neuromuscular control could result in deleterious effects to the patient. As a result, the humeral head may not center itself within the glenoid, thereby compromising the surrounding static stabilizers. The patient with poor neuromuscular control may exhibit excessive humeral head migration with the potential for injury, an inflammatory response, and reflexive inhibition of the dynamic stabilizers.

Several authors have reported that neuromuscular control of the glenohumeral joint may be negatively affected by joint instability.

Lephart et al compared the ability to detect passive motion and the ability to reproduce joint positions in normal, unstable and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared to both normal shoulders and shoulders undergoing surgical stabilization procedures.

Smith and Brunoli reported a significant decrease in proprioception following a shoulder dislocation.

Blasier et al reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.

Zuckerman et al noted that proprioception is affected by the patient’s age with older subjects exhibiting diminished proprioception than a comparably younger population.

Thus, the patient presenting with traumatic or acquired instability may present with poor neuromuscular control that must be addressed.

 

Factor # 6 – Pre-Injury Activity Level

The final factor to consider in the nonoperative rehabilitation of the unstable shoulder is the arm dominance and the desired activity level of the patient.

If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free ROM and adequate strength has been achieved.

Patients whose functional demands involve below shoulder level activities will follow a progressive exercise program to return full ROM and strength. The success rates of patients returning to overhead sports after a traumatic dislocation of their dominant arm are often low, but possible.

Arm dominance can also significantly influence the successful outcome. The recurrence rates of instabilities vary based on age, activity level and arm dominance. In athletes involved in collision sports, the recurrence rates have been reported between 86-94%.

 

Keys to Shoulder Instability Rehabilitation

To summarize, nonoperative rehabilitation of shoulder instability has many subtle variations.  To simplify my thought process, I always think of these 6 key factors before I decide what I want to do.  I hope these factors help you too.  What other factors do you consider when designing rehabilitation programs for shoulder instability?

 

Learn How I Evaluate and Treat the Shoulder

shoulder seminarWant to learn exactly how I rehabilitate shoulder instability?

I have a whole lesson on this as part of my comprehensive online program on the Evidence Based Evaluation and Treatment of the Shoulder at ShoulderSeminar.com.  If you want to learn exactly how I evaluate and treat the shoulder, including shoulder instability, this course is for you.  You’ll be an expert on shoulders!

 

 

 

 

Clinical Examination of Superior Labral Tears – What is the Best Special Test for a SLAP Tear?

**Updated in 2017**

What is the best test for a SLAP tear?  That is a pretty common question that I hear at meetings.

Clinical examination to detect SLAP lesions is often difficult because of the common presence of concomitant pathology in patients presenting with this type of condition. Andrews has shown that 45% of patients (and 73% of baseball pitchers) with superior labral lesions have concomitant partial thickness tears of the supraspinatus portion of the rotator cuff.  Mileski and Snyder reported that 29% of their patients with SLAP lesions exhibited partial thickness rotator cuff tears, 11% complete rotator cuff tears, and 22% Bankart lesions of the anterior glenoid.

The clinician should keep in mind that while labral pathologies frequently present as repetitive overuse conditions, such as those commonly seen in overhead athletics, the patient may also describe a single traumatic event such as a fall onto the outstretched arm or an episode of sudden traction, or a blow to the shoulder.  This is an extremely important differentiation you need to make when selecting which tests you should perform.

A wide variety of potentially useful special test maneuvers have been described to help determine the presence of labral pathology.  Lets review some of them now.

This article is part of a 4-part series on SLAP Lesions

Special Tests for a SLAP Tear

There are literally dozens of special tests for SLAP tears of the shoulder.  I am going to share some of the most popular SLAP tests.

 

Active Compression Test

active compression SLAP testThe active compression test is used to evaluate labral lesions and acromioclavicular joint injuries. This could be the most commonly performed test, especially in orthopedic surgeons.  I am not sure why, though, I do not think it is the best.

The shoulder is placed into approximately 90 degrees of elevation and 30 degrees of horizontal adduction across the midline of the body. Resistance is applied, using an isometric hold, in this position with both full shoulder internal and external rotation (altering humeral rotation
against the glenoid in the process). A positive test for labral involvement is when pain is elicited when testing with the shoulder in internal rotation and forearm in pronation (thumb pointing toward the floor). Symptoms are typically decreased when tested in the externally rotated position or the pain is localized at the acromioclavicular (AC) joint.

O’Brien et al found this maneuver to be 100% sensitive and 95% specific as it relates to assessing the presence of labral pathology.  These results are outstanding, maybe too outstanding. Pain provocation using this test is common, challenging the validity of the results. In my experience, the presence of deep and diffuse glenohumeral joint pain is most indicative of the presence of a SLAP lesion. Pain localized in the AC joint or in the posterior rotator cuff is not specific for the presence of a SLAP lesion. The posterior shoulder symptoms are indicative of provocative strain on the rotator cuff musculature when the shoulder is placed in this position.

The challenging part of this test is that many patients will be symptomatic from overloading their rotator cuff in this disadvantageous position.

  • Sensitivity: 47-100%, Specificity: 31-99%, PPV: 10-94%, NPV: 45-100% (a lot of variability between various authors)

 

Biceps Load Test

The biceps load testBiceps Load SLAP Test involves placing the shoulder in 90 degrees of abduction and maximally externally rotated. At maximal external rotation and with the forearm in a supinated position, the patient is instructed to perform a biceps contraction
against resistance. Deep pain within the shoulder during this contraction is indicative of a SLAP lesion.
The original authors further refined this test with the description of the biceps load II maneuver. The examination technique is similar, although the shoulder is placed into a position of 120 degrees of abduction rather than the originally described 90 degrees.  The biceps load II test was noted to have greater sensitivity than the original test.  I like both of these tests and usually perform them both.
  • Sensitivity: 91%, Specificity: 97%, PPV: 83%, NPV: 98% for Biceps Load I; Sensitivity: 90%, Specificity: 97%, PPV: 92%, NPV: 96% for Biceps Load II

 

Compression Rotation Test

Compression Rotation SLAP TestThe compression-rotation test is performed with the patient in the supine position. The glenohumeral joint is manually compressed through the long axis of the humerus while, the humerus is passively rotated back and forth in an attempt to trap the labrum within the joint. This is typically performed in a variety of small and large circles while providing joint compression when performing this maneuver, in an attempt to grind the labrum between the glenoid and the humeral head. Furthermore, the examiner may attempt to detect anterosuperior labral lesions by placing the arm in a horizontally abducted position while providing an anterosuperior directed force. In contrast, the examiner may also horizontally adduct the humerus and provide a posterosuperiorly directed force when performing this test.  I think of this test as “exploring” the joint for a torn labrum.  It is hit or miss for me.

  • Sensitivity: 24%, Specificity: 76%, PPV: 90%, NPV: 9%

 

Dynamic Speed’s Test

dynamic speeds SLAP testThe Speed’s biceps tension test has been found to accurately reproduce pain in instances of SLAP lesions.  I have personally not seen this to be true very often.

It is performed by resisting downwardly applied pressure to the arm when the shoulder is positioned in 90 degrees of forward elevation with the elbow extended and forearm supinated. Clinically, we also perform a new test for SLAP lesions.

Kevin Wilk and I developed a variation of the original Speed’s test, which we refer to as the “Dynamic Speed’s Test.”  (I came up with the name, what do you think?)  During this maneuver, the examiner provides resistance against both shoulder elevation and elbow flexion simultaneously as the patient  elevates the arm overhead. Deep pain within the shoulder is typically produced with shoulder elevation above 90 degrees if this test is positive for labral pathology.

Anecdotally, we have found this maneuver to be more sensitive than the originally described static Speed’s test in detecting SLAP lesions, particularly in the overhead athlete.  To me, it seems like you only get symptoms with greater degrees of elevation, making the original Speed’s Test less sensitive in my hands.

  • Sensitivity: 90%, Specificity: 14%, PPV: 23%, NPV: 83% for the Speed’s test

 

Clunk and Crank Tests

clunk crank slap testThe clunk test is performed with the patient supine. The examiner places one hand on the posterior aspect of the glenohumeral joint while the other grasps the bicondylar aspect of the humerus at the elbow. The examiner’s proximal hand provides an anterior translation of the humeral head while simultaneously rotating the humerus externally with the hand holding the elbow.  The mechanism of this test is similar to that of a McMurray’s test of the knee menisci, where the examiner is attempting to trap the torn labrum between the glenoid and the humeral head. A positive test is produced by the presence of a clunk or grinding sound and is indicative of a labral tear.

The crank test can be performed with the patient either sitting or supine. The shoulder is elevated to 160 degrees in the plane of the scapula. An axial load is then applied by the examiner while the humerus is internally and externally rotated in this position. A positive test typically elicits pain with external rotation. Symptomatic clicking or grinding may also be present during this maneuver.  These tests seem to do well with finding a bucket-handle tear of from a Type III or Type IV SLAP lesion more than anything else for me.

  • Sensitivity: 39-91%, Specificity: 56-93%, PPV: 41-94%, NPV: 29-90%

 

 

2 New(er) Special Tests for SLAP Lesions

In addition to the classic SLAP tests that have been described, there are two additional tests that gained popularity more recently.

I wanted share a video that I have on YouTube that demonstrates these two tests. These were actually published in a paper I wrote in JOSPT a few years ago, but I have modified them a little and wanted to share. These two tests are both excellent at detecting peel-back SLAP lesions, specifically in overhead throwing athletes, but are useful for any population. I share these two tests because I know that there is a lot of confusion regarding the “best” test. These may not be them, but in my hands, both have been extremely helpful and, more importantly, accurate.

Pronated Load SLAP Test

The first test is the “Pronated Load Test,” it is performed in the supine position with the shoulder abducted to 90° and externally rotated. However, the forearm is in a fully pronated position to increase tension on the biceps and subsequently the labral attachment. When maximal external rotation is achieved, the patient is instructed to perform a resisted isometric contraction of the biceps to simulate the peel-back mechanism. This test combines the active bicipital contraction of the biceps load test with the passive external rotation in the pronated position, which elongates the biceps. A positive test is indicated by discomfort within the shoulder.

 

Resisted Supination External Rotation SLAP Test

The second test was described by Myers in AJSM, called the “Resisted Supination External Rotation Test.” Dr. Myers was a fellow at ASMI and a good friend of mine, he really wanted to call this the SUPER test (for SUPination ER) but I was one of many that advised him against this for obvious reasons!

During this test, the patient is positioned in 90° of shoulder abduction, and 65-70° of elbow flexion and the forearm in neutral position. The examiner resists against a maximal supination effort while passively externally rotating the shoulder. Myers noted that this test simulates the peel-back mechanism of SLAP injuries by placing maximal tension on the long head of the biceps by supinating.

Myers’ study of 40 patients revealed that this test had better sensitivity (82.8%), specificity (81.8%), positive predictive value (PPV) (92.3%), negative predictive value (NPV) (64.3%), and diagnostic accuracy (82.5%) compared to the crank test and extremely popular O’Brien’s or active compression test. A positive test is indicated by discomfort within the shoulder.

 

When Do You Perform These Tests?

Now that you know a bunch of special tests for SLAP tears, the real key is understanding “when” to pick each test.  In my mind, they all are slightly different and may even be better at detecting different types of SLAP lesions.  I have an Inner Circle webinar that discusses this and shows you my clinical algorithm on how and why I perform special tests to diagnose a SLAP tear:

 

 

Learn Exactly How I Evaluate and Treat the Shoulder

shoulder seminarIf you want to learn even more about the shoulder, my online course at ShoulderSeminar.com will teach you exactly how I evaluate and treat the shoulder.  It is packed with tons of educational content that will help you master the shoulder, including detailed information on the clinical examination and treatment of SLAP tears.

 

 

 

Special Tests to Diagnose SLAP Tears

The latest Inner Circle webinar recording on Special Tests to Diagnose SLAP Tears is now available.

 

 

Special Tests to Diagnose SLAP Tears

This month’s Inner Circle webinar is on Special Tests to Diagnose SLAP Tears.  In this presentation, I review the many, many different SLAP special tests that exist and explain when and why you would choose certain ones for different people.

This webinar will cover:

  • Why there are so many different SLAP special tests
  • The common mechanisms of injury for SLAP tears
  • Why a good subjective history should lead your clinical examination
  • How to choose specific special tests for specific people
  • How to perform my most commonly used SLAP tests

To access this webinar:

 

 

Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair

There continues to be great debate over the most appropriate rehabilitation progression following rotator cuff repair. Although our surgical techniques have gradually progressed from full open repairs, to smaller mini-open repairs, to the current standard all-arthroscopic repairs, many clinicians continue to utilize the same rehabilitation guidelines from past invasive procedures.

And more confusing is the lack of consensus among surgeons regarding the optimal postoperative rehabilitation protocol following arthroscopic rotator cuff repair.  Protocols can vary as drastically as beginning gentle passive range of motion and isometric exercises post-operative week 1 to delaying 12 weeks for the initiation of similar exercises.

I want to share the postoperative protocol that I have developed with Kevin Wilk and James Andrews.

It details the postoperative guidelines that we have used since the shift to arthroscopic rotator cuff repairs several years ago. While there is still a lack of efficacy studies, these guidelines have proven to us to be both safe and effective in the rehab of 1000’s of patients at our clinics.

Before downloading the protocol, I want to explain the goals of rehabilitation and what I believe are the 3 keys to rehabilitation. These principles are the cornerstone behind the protocol you are about to download.

 

Goals of Rehabilitation Following Rotator Cuff Repair

When rehabilitating after an arthroscopic rotator cuff repair surgery, the main goals of the rehabilitation protocol should be:

  • Protect the integrity of the rotator cuff repair
  • Minimize postoperative pain and inflammation
  • Restore passive range of motion
  • Restore strength and dynamic stability of the shoulder
  • Restore active range of motion
  • Return to functional activities

Pretty simple, right?  When you lay it out like that, we simply combine those goals with what we know about the basic science of healing tissue and you can fill in the gaps and individualize a program based on the patient and your treatment preferences.

 

The 3 Most Important Keys to Rotator Cuff Repair Rehabilitation

Now that you understand the goals, I want to share what I consider the 3 most important keys to rotator cuff repair rehabilitation.  Follow the goals above and focus on these 3 keys and you’ll be well on your way to full functional recovery:

  1. shoulder-shrug-signRestore full passive ROM quickly. It is extremely easy to lose motion following surgery. In my opinion this is caused by scarring in the subacromial space as well as loss of the redundancy of the glenohumeral capsule with immobilization. This is one of the common “rookie mistakes” I see with students and new graduates. Passive range of motion should be initiated immediately following surgery in a gradual and cautious fashion. Studies have shown that passive range of motion into flexion and external rotation actually decreases strain in the rotator cuff repair (still need to be cautious with adduction, extension, and internal rotation).
  2. Restore dynamic humeral head control. This is likely the most important goal of postoperative rehabilitation, other than maintaining the integrity of the repair. What this means is to restore the rotator cuff’s ability to center the humeral head within the glenoid fossa. Have you ever seen a patient following repair that had a shoulder “shrug” sign? That is caused by the inability of the cuff to compress the humeral head and the resultant superior humeral head migration. This is why it is imperative to begin gentle isometrics, rhythmic stabilization drills, and other drills to re-educate the rotator cuff.
  3. Maximize external rotation strength. I often refer to external rotation as the key to the shoulder. Weakness of ER is common in almost every pathology and strengthening of the area is extremely important to balance the anterior and posterior balance of cuff. Several studies have shown that ER strength takes the longest amount of time to restore after rotator cuff repair. The longer this area is weak, the more difficult it will be to stabilize the joint.

 

 

Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair

physical therapy rehabilitation protocolsIf you are interested in using the protocols that I have helped develop with Kevin Wilk and Dr. James Andrews, we have recently revised and expanded all of our protocols and made them completely online and downloadable.  Our physical therapy rehabilitation protocols have been published in several journals over the years and based on our decades of research, scientific evidence, and experience.

They are the most widely used and respected rehabilitation protocols today.

Want to see what our protocols include?  You can download our 3 most popular protocols for FREE:

  • Accelerated rehabilitation following ACL reconstruction using a patellar tendon autograft
  • Rehabilitation following arthroscopic rotator cuff repair for a type II medium-large sized tear
  • Thrower’s ten exercise program

 

physical therapy rehabilitation protocols online accessOur entire collection includes over 175 nonoperative, preoperative, postoperative protocols for shoulder, elbow, hip, knee, foot, and ankle.  There are several variations of many protocols to account for many specific procedures and concomitant surgeries.  Plus, we have several of our exercise handouts and interval return to sport programs.

If you work in an outpatient orthopedic or sports medicine clinic, these protocols are an invaluable resource to help guide your treatment approach.