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How Fast Do You Rehab Your Rotator Cuff Repair Patients?

That seems to be one of the most common questions I get regarding rehabilitation of the shoulder.  It seems like clinicians want to know how everyone else is rehabilitation their patients following rotator cuff repair surgery.  My guess is because most people feel that their physicians are too restrictive in their postoperative guidelines?  Does that sound like you?

DSC01366Unfortunately the most optimal rehabilitation progression following a cuff repair has not  been documented.  There are no research reports stating that one technique is better than another, that starting ROM immediately is better than not, or that avoiding isometrics for 12 weeks is safer for the repair than beginning immediately.

Notice above that I highlighted “optimal.”  That was a specific choice of wording.  Optimal can mean many things.  For these patients it could mean “safest rehabilitation progression” or even “most effective rehabilitation progression.”  But even those phrases are vague.

Let me ask you a question:

What is your definition of the optimal outcome following rotator cuff repair?

Is it that the patients returns to their premorbid work or athletic activity?  That the patient restores ROM and strength as quickly and safely as possible?  Or that the patient have an intact cuff repair when performing a MRI or ultrasound 2 years after surgery?

We may all have a different answer to that question, but let me share with your how I would answer.  The most optimal outcome following rotator cuff repair for me is having your patient return to their normal activities as quickly and safely as possible.  I would bet that if you asked this question to a surgeon, they would respond with the above comment regarding having the repair intact at time X after surgery.  I would also bet that if you ask the patient this same question, they would respond with something along the lines of “I want to be able to lift my arm overhead while doing [insert activity here!] without pain.”

What would you say if I told you that 35% of rotator cuff repair surgeries fail?  Again, I highlighted “fail” because I am talking about two research reports that examined the percentage of repairs that were still intact 5 years after surgery (Harryman: JBJS ‘91 & Fealy: Arthroscopy ‘02).  Here are some interesting findings:

  • 35% of all tears fail
  • 20% of supraspinatus repairs fail
  • 50% of repairs of two tendons fail
  • 68% of repairs of three tendons fail
  • 25% of repairs to people aged 34-55 fail
  • 35% of repairs to people aged 56-70 fail
  • 45% of repairs to people aged 71-85 fail

Pretty shocking, right?

This is the primary factor why I believe surgeons promote a decelerated rehabilitation approach – they do not want failure

Well how about this information, also from those studies:

  • 96% of patients with intact cuff report being satisfied
  • 87% without cuff intact are STILL satisfied

What does this mean to me?  This tells me that integrity of the repair is not the most optimal factor associated with success following rotator cuff repair.  I would argue that we should be more worried about satisfaction than integrity of the cuff

Now don’t get me wrong, I realize that if your cuff remains intact that you will likely have a better outcome.  I am just saying that I don’t believe that we need to be unnecessarily cautious and decelerate our rehabilitation approaches.

There are safe and effective ways to achieve satisfaction and integrity of the repair

Want to know how I believe we can achieve this?  Want to know how I rehabilitate my patients using what limited evidence we have?  Want to know what I do each week following surgery, and more importantly – why?

Click here to see more about how I rehabilitation rotator cuff repair patients and download free copy of my arthroscopic rotator cuff repair protocol.

Harryman DT 2nd et al (1991). Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff J Bone joint Surg, 73 (7), 982-989 DOI: 12098132

The Effect of Throwing on Shoulder Characteristics

Sorry, this took me much longer than I expected to figure out the technology of getting a PowerPoint onto the blog.  Here is the first of my two talks from last week’s ASMI Injuries in Baseball course in Houston.  Hope you enjoy as I work out the kinks.  I will post my second talk next week.

The Effect of Overhead Throwing on Shoulder Strength, Motion, Scapula Position, and Proprioception

Choosing Which SLAP Special Test to Perform During Your Examination

There are so many different special tests for superior labral, or SLAP tears, how do you chose which to perform?  I have a couple of different ways that I determine which tests to perform, but first, lets see what the evidence has to say regarding all these tests.

Special tests for SLAP tears have come under much scrutiny in recent years as conflicting reports on the accuracy of these tests have been published.  What you will find in research reports regarding these tests is that the original citation for each of these tests seem to have extremely high sensitivity, specificity, and negative and positive predictive values.  A good example is the active compression test.  The original article by O’Brien had shown 100% sensitivity, 98.5% specificity, positive predictive value of 94%, and a negative predictive value of 100%.  These are pretty high numbers, so high that they are actually even better than MRI!  Since then, no other other author has shown values like this.

This is not isolated to the active compression test, almost every SLAP test described is similar.

Dessaur and Magray reviewed 17 peer-reviewed manuscripts and noted that the majority of papers reporting highly accurate tests for SLAP lesions were of low quality with the results not supported by other researchers.  Jones and Galluch agreed and noted that subsequent independent testing of SLAP tests showed much poorer performance that the originally published studies.  There are many other research reviews and meta-analysis studies that agree.

An interesting study from Oh et al in AJSM showed that a combination of tests used together may yield the best results.  They state that if you combine a couple of tests that have shown to have good sensitivity with a couple of tests that show good specificity, they reached sensitivity and specificity values between 70-95%.  This makes sense to me as none of these tests are perfect, think of it as covering your bases with a few tests.

I feel that this may be for multiple reasons.

Different patient populations will present with different mechanisms of injury.  In most studies, several variations of SLAP lesions are grouped together to obtain enough statistical power to analyze the data. It is my opinion that different tests will result in different specificity and sensitivity results based on the variation of SLAP lesion present. For example, overhead athletes with a type II or IV posterosuperior peel back SLAP lesion may be more symptomatic during tests that simulate the aggravating position and mechanism of injury, such as the biceps load II, clunk, crank, pain provocation tests, and pronated load test; whereas patients with type I or III SLAP lesions due to a traumatic type of injury may be more symptomatic during tests that provide compression to the labral complex such as the active-compression, compression-rotation and anterior slide tests.

Further investigation on the diagnostic characteristics of these tests based on the type of SLAP lesion is warranted.

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

Choosing Which SLAP Test to Perform During Your Examination

I know it sounds cliché, but first and foremost, your subjective examination should lead your clinical tests.  If you patient is a construction worker who fell on an outstretched arm, you probably don’t need to perform any tests that simulate a peel-back lesion.  And vice-versa, if your patient is a recreational tennis player with a desk job that only feels pain while serving in tennis, you can probably jump straight to the peel-back tests.

For simplicity sake, lets divide SLAP tears into three categories (for more information read my post on classifying SLAP lesions):

  • Overhead Athletes that present with peel-back lesions
  • Compression injuries from someone that falls onto an outstretched arm or on the side of the shoulder.  This will compress and sheer the labrum, similar to a meniscus tear.
  • Traction injuries from a sudden eccentric biceps contraction.  This one is the least common and I even have some mild doubts of this mechanism.

Special tests for SLAP tears

Choosing a SLAP Test Based on The Mechanism of Injury

Here are the tests I perform based on the type of injury mechanism.  I actually find this to be much more helpful in selecting my tests than by selecting based on research results only.

Remember, we have no idea the exact patient population or injury mechanism for those research reports, you can not go on them alone!  You do, however, have this information for the patient that is sitting in the exam room right in front of you!

For detailed descriptions of each test, please refer back to my article on special tests for SLAP lesions.

Peel-Back Injury (Overhead Athlete):

  • Pronated load
  • Resisted Supination ER
  • Biceps Load

Compression Injury:

  • Active compression
  • Compression rotation
  • Clunk

Traction Injury:

  • Dynamic Speed’s
  • Active compression

Choosing a Test Based on The Type of SLAP Tear

If you want to try to determine the type of SLAP tear, Type I, Type II, Type III, or Type IV, this is more challenging but you can try to give it a shot based on the below table.  This is definitely more of guess work, but the more information we can try to obtain the better.

Remember that each of the tests described will try to reproduce symptoms in different ways, you should try to correlate the pathology of the different types of SLAP lesions with specific special tests.  Use this as a grain of salt, it may be helpful but hasn’t been backed by research to show how well this classification works (this more for just a game I play against myself!)

Type I SLAP:

  • Compression rotation

Type II SLAP:

  • Pronated load
  • Resisted Supination ER
  • Biceps Load

Type III and IV SLAP:

  • Clunk and Crank
  • Compression Rotation

In summary, the research results of the numerous SLAP tests are extremely variable and should not be relied on solely to determine which test to perform on your patient.  In contrast, I propose that you:

  • Use the patient’s mechanism of injury to lead your decision on which group of tests to perform.  The subjective exam is important!
  • Perform a cluster of a few tests for that group that have shown decent sensitivity and specificity to enhance your results using a group of tests rather than just one.
  • Don’t hang your hat on one test.  It may be good for a specific patient population and not another
  • Don’t get frustrated, SLAP lesions are difficult to detect on clinical examination.  When in doubt refer back to the doctor for a MRI.

When Do You Perform These Tests?

Now that you know the real key is understanding “when” to pick each test, I want to walk you through all these in one of my Inner Circle webinars.  In my mind, they all are slightly different and may even be better at detecting different types of SLAP lesions.  This Inner Circle webinar 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 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.

Glenohumeral Arthritis in the Athlete

Arthritis of the glenohumeral joint is a challenging shoulder injury for athletes.  As our generations change, we will continue to see less and less sedentary patients in the later stages of life. Their functional goals in rehabilitation will be much greater than in past decades.  Traditionally, care for the older individual with glenohumeral osteoarthritis was based solely on pain relief rather than maximization of functional activities.  Options included activity modification, medications, injections, physical therapy, and possibly joint replacement.
Patients now want to continue with recreational activities such as tennis, golf, and swimming.  This is especially true when a patient has an early onset of arthritis symptoms.  Recent attention has been made in the orthopedic communities to attempt to maximize function in these patients as much as possible.
a girl playing golf
 Photo by Fevi Yu
This month’s journal issue of Operative Techniques in Sports Medicine focuses exclusively on this topic, glenohumeral arthritis in the athlete. The issue includes descriptive current concepts articles on all aspects of care of the arthritic shoulder, except for physical therapy unfortunately.
The issue begins with a nice article focusing mainly on evaluation and a treatment algorithm.  The article is fairly thorough with reviews of several arthritic conditions (primary osteoarthritis, dislocation arthropathy, osteonecrosis, and rheumatoid arthritis to name a few) and then an algorithmthat sets up the following sequence of articles on arthroscopic management, biological resurfacing, surface replacement, conventional shoulder arthoplasty, and reverse total shoulder arthroplasty.  These are surely exciting times as many new procedures are being developed to maximize function in these patients.  There are some generic postoperative information for rehabilitation but this is clearly not the focus of the issue.  Still, the issue is excellent and a great place to freshen up on the latest management options for the athletic patient with glenohumeral arthritis.
 
Luckily, there have also been some great articles published recently regarding the rehabilitation of glenohumeral arthritic in athletes
Reg Wilcox over at the Brigham and Womans Hospital in Boston has published two excellent articles on the rehabilitation following total shoulder arthroplasty in JOSPT in 2005 and following reverse total shoulder arthroplasty in JOSPT in 2007.  I had the pleasure of speaking at the MA state APTA meeting last year with Reg and Dr. Higgins, one of his co-authors, and they truely did an excellent job.  These two articles have been especially helpful in my practice.
Todd Ellenbecker, who am sure is recognized by many of the readers, also published a case study in JOSPT earlier in 2008 on humeral resurfacing hemiarthroplasty with a meniscal allograft in a young patient.  This was also a good read and very interesting case.  We certainly are coming a long way with our treatment interventions.  Todd was also kind enough to contribute a chapter on glenohumeral arthritis in my book, The Athlete’s Shoulder (which I received information yesterday that it is finally published and available!).
Does anyone else have any articles on the topic of glenohumeral arthritis in the athlete to recommend?

Preventing Shoulder Stiffness After Rotator Cuff Repair Surgery

I think that stiffness following any surgery, especially rotator cuff repair, is a common problem that we face in physical therapy. I found a great blog today by another physical therapist, Rod Henderson. As I was reading I noticed that we shared some similar interests and taste for good research! He did an excellent job reviewing a research article on postoperative stiffness following rotator cuff repair. The article was published in 2005 in CORR – Clinical Orthopedics and Related Research.

To summarize, it appears that if you are tight going into surgery, you are going to be tight coming out of surgery. Makes sense. Also, patients that are stiff during the first 4-6 weeks postop will eventually catch up. But I have to think that they are much less satisfied during the first 3 months after surgery than the patients that did not develop stiffness. And isn’t satisfaction really what we are trying to achieve?

This is an important topic as I hear questions about this frequently at meetings and seminars. I also feel that stiffness can be prevented by one of two ways:

  1. Get the patients into rehabilitation quickly after surgery. Unfortunately delaying the start of PT is a trend that I don’t like from orthopedic surgeons. There is still a lot of debate over the safety and efficacy of postoperative rehabilitation programs following cuff repair. With full open repairs (and detachment of deltoid tissue) there was a need for delayed rehab, but as we transition from open to mini-open to full arthroscopic repairs, our rehabilitation should progress in parallel. Fixation strength of arthroscopic repairs have been shown to be as strong as mini-open repairs so I am not sure why the delay. I don’t think all surgeons share our thought that that gentle, controlled therapy can be safe and enhance patient satisfaction. This is a hot topic now at all the national meetings and I am involved in a group of all the top PTs in the USA in drafting a consensus statement on postop cuff rehab. Hopefully we will start to make an impact over time.
  2. Begin early passive range of motion. While internal rotation, adduction, and extension are all potentially harmful for a rotator cuff repair, passive flexion and external rotation have actually been shown to reduce tension on a rotator cuff repair. You want to get your cuff patients moving quickly in these directions because there is often scarring in the subacromial space (especially with a concomitant subacromial decompression) and a chance to develop inferior capsular restrictions.

Rather than rehash the entire information, click here to read the full review on Rod’s blog or click here to view the abstract from CORR.

Fatigue of the Rotator Cuff Causes Altered Shoulder Mechanics and Impingement

Another interesting article from the most recent issue of Journal of Athletic Training on rotator cuff fatigue and glenohumeral kinematics. In this study, the authors used dynamic fluroscopic video to assess superior humeral head migration in 20 asymptomatic subjects before and after fatigue of the rotator cuff. The assessment of migration during a dynamic activity is a fairly novel approach as previous studies that have attempted to quantify superior humeral head translation have used static imaging such as radiographs and MRI.

During the study the authors used the prone horizontal abduction (with thumbs up) exercise to fatigue the cuff until there was a documented decrease of at least 40% strength. This was an important part of the study, as a reader I want to be sure that fatigue had occurred and a 40% drop is significant for me. I must say, though, that I wish the authors had performed a more specific rotator cuff exercise, such as simple external rotation. The prone exercise has shown EMG activity of the cuff but also the deltoid and scapula musculature.

Results of the study show that humeral head migration increased by an average of 0.79mm during elevation in a fatigued state. While this seems small, keep in mind that the average subacromial space is between 2mm and 14mm in healthy subjects (can be about 50% smaller in pathological patients), thus reducing subacromial space by up to 40%!

Clinical Implications

RTC fatigue can lead to shoulder impingement
. An interesting component of the article that the authors did not bring up in their discussion was that the humeral head actually migrated inferior prior to fatigue as the RTC acted to maintain the humeral head within the glenoid fossa as the deltoid provided a superior orientated force vector. After the fatigue, not only did the humeral head not migrate inferior, it moved superiorly. This has obvious implications for subacromial impingement. Both strength and endurance of the cuff should be addressed in rehabilitation, makes sense why a deconditioned person so much more likely to develop shoulder impingement.

deltoid pullThe rotator cuff should never be worked to failure. The fatigue protocol used by the authors lasted for less than 90 seconds. That is all it took for the RTC to loose 54% of it’s strength. Now think about that last time you had a patient come to you with “impingement” that reported playing tennis or golf for the first time in months, or even more simply, painting a room in their house. With only 90 seconds of activity the cuff fatigue enough to decrease your subacromial space by up to 40%. What should your treatment be for that patient? Minimize the initial inflammation, work on cuff strength & endurance but by all means, DON’T work the cuff to failure.

The rotator cuff should NEVER be worked to failure!

I never understood this training technique. If you work the cuff to failure, then what is going to dynamically stabilize the humeral head later that day when you a reaching overhead?

As always, please comment with your thoughts and experience!