Rehabilitation Protocol: Small to Moderate Rotator Cuff Tear - PDF Document

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  1. Rehabilitation Protocol: Small to Moderate Rotator Cuff Tear Department of Orthopaedic Surgery Lahey Hospital & Medical Center, Burlington 781-744-8650 Lahey Outpatient Center, Lexington 781-372-7020 Lahey Medical Center, Peabody 978-538-4267 Department of Rehabilitation Services Lahey Hospital & Medical Center, Burlington 781-744-8645 Lahey Hospital & Medical Center, Wall Street, Burlington 781-744-8617 Lahey Danvers 978-739-7400 Lahey Outpatient Center, Lexington 781-372-7060

  2. ◄Overview Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the humerus. Multiple factors can impact the repair, including tissue quality, the age and size of the tear, compliance with postoperative restrictions, patient age and smoking history. The goals of rehabilitation are first to protect the repair and second to restore pain free function. Understanding the characteristics of the tear as well as the surgical approach are important considerations in establishing a postoperative treatment plan. Millet et al 1 found that humeral head position has been shown to have an impact on blood flow. Hypovascularity of the supraspinatus has been shown with the arm adducted at the side. The safest resting position after rotator cuff repair is 30° of elevation in the scapular plane, with 0° to 60° of external rotation which can be attained with the abduction sling. Appropriate communication between the therapist, patient and surgeon is key to a successful outcome. 1 Millett PJ et al. Rehabilitation of the rotator cuff: an evaluation-based approach. J Am Acad Orthop Surg 2006 Oct; 14(11): 599-609 Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 2

  3. ◄Phase I Protective Phase 0−6 Weeks Goals • • • • • • Protection of surgical site Gradual increase of passive range of motion Decrease pain and inflammation Maintain full C-spine, elbow, wrist and hand motions Re-establish dynamic scapular stability Participate in ADLs while protecting repair Precautions • • • • • • • • • • • • • • Maintain arm in abduction sling/brace until end of week 6 or as advised by surgeon Wear sling at night while sleeping Remove sling/brace only for exercise or showering Avoid excessive stretching Avoid sudden motions Avoid lying on operated arm Avoid overstressing the healing tissues Do not use arm beyond hand to mouth Do not lift elbow away from body Do not lift objects Do not reach arm behind back Do not support body weight on hands Keep elbow at side with all activities including use of computer Do not drive until authorized by surgeon Days 1–7 • • • • • • Wear sling during the day and at night Remove sling for showering/bathing Remove sling 4 to 5 times per day for gentle elbow, forearm, wrist and finger exercises Ball squeezing exercises Neck Exercises Ice for pain and inflammation 20 minutes as needed, best to allow 2 hours between applications Pendulum exercises if advised by surgeon, depending on the quality of the repair Scapular retraction and depression • • Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 3

  4. Weeks 2−4 • • • • Continue above Pendulum exercises Ice as needed Painfree PROM by therapist in supine flexion, scaption, internal and external rotation (in scapular plane) PROM Goals: Flexion: 100 ˚ Scaption: 90 ˚ IR: 45 ˚ ER 45 ˚ • Weeks 4−6 • Continue program above Manual Therapy oGentle scapular/glenohumeral joint mobilization as indicated to progress PROM oSoft Tissue Mobilization as indicated oUpper trapezius stretching ROM oAvoid superior humeral head migration or scapular hiking (shrug sign) with all motion oProgress PROM with goal of full painfree PROM by end of 6 weeks Exercise oBall rolling on table with elbow below shoulder level oInitiate AAROM with dowel in supine Flexion to 145˚ oAAROM overhead pulleys flexion/scaption oSubmaximal pain free isometrics with flexed elbow: Flex/Ext/Abd/IR/ER oGeneral conditioning while protecting shoulder (walking, stationary bike) at week 5 Functional Activities oUtilize sling for protection in crowds oDiscontinue sling at end of week 6 unless advised by surgeon oGradual increase in functional activity while avoiding superior humeral head migration oResume driving if advised by surgeon Criteria for progression to Phase II Painfree PROM oFlexion to ≥125° oPassive ER in scapular plane to ≥ 75° (if uninvolved shoulder PROM >80°) oPassive IR in scapular plane to ≥ 75° (if uninvolved shoulder PROM >80°) oPassive abduction ≥ 120° Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 4

  5. ◄Phase II – Intermediate Phase Active Motion and Early Strengthening 7−9 weeks Goals • PROM full and pain free by week 10 • Decrease pain and inflammation • Gradual increase in strength • Dynamic scapular stabilization • Optimize neuromuscular control • Resume light functional activities Precautions • No excessive movements behind back • Avoid sudden, jerking motions • No lifting greater than 5# • Keep load close to body • Avoid heavy housework/yard work – No vacuuming/shoveling Weeks 7−9 • • Continue program above Continue ice/modalities as needed Manual Therapy oSoft tissue mobilization over healed incision oGentle scapular/glenohumeral joint mobilization as indicated to regain full painfree PROM ROM oProgress painfree PROM oProgress AAROM to tolerance oAAROM behind back Exercise oDynamic shoulder stabilization in supine to facilitate functional movement oNeuromuscular re-education to address scapular mechanics oInitiate deloaded /MET pulleys oInitiate AROM  Sidelying flexion and scaption  Active ER to 30° – 40°  Closed kinetic chain activities • Ball on wall • Wall pushups Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 5

  6. oInitiate strengthening program NO SHRUG!  Resisted IR/ER with tubing (axillary roll to avoid fully adducted position)  Isotonic strengthening of scapular stabilizers  Initiate prone strengthening to neutral, avoid activation of upper trapezius  Resisted elbow flexion and extension Functional Activities oNo lifting greater than 5# oKeep load close to body oResume light functional activities oAvoid heavy housework/yardwork – No vacuuming/shoveling Criteria for progression to Phase III oFull pain free AROM, NO SHRUG! oDynamic shoulder stability oGradual restoration of shoulder strength, power and endurance oOptimize neuromuscular control oGradual return to functional activities Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 6

  7. ◄Phase III Early Strengthening Weeks 10−12 Goals • • • • Restoration of full and pain free AROM Gradual Return to functional activities Gradual increase in strength Optimize neuromuscular control Precautions • • • • • • No excessive movements behind back Avoid sudden, jerking motions No overhead lifting Resume normal daily activities with caution Check with surgeon re: return to sports and lifting restrictions Typical return to sports is 6 to 8 months with clearance of surgeon Manual Therapy oContinue soft tissue mobilization over healed incision oMore aggressive scapular/glenohumeral joint mobilization as indicated to regain full painfree PROM/AROM ROM oProgress AROM to tolerance Exercise oInitiate resistive exercise gradually oSidelying ER/IR oStanding scaption, flexion and abduction oProgress closed kinetic chain exercises oTrunk and lower body strengthening (especially in throwing athletes) Functional Activities oResume normal daily activities with caution oCheck with surgeon re: return to sports and lifting restrictions oTypical return to sports is 6 to 8 months with clearance of surgeon Criteria to Discontinue PT oFull painfree AROM with good mechanics unless patient requires further vocational or sport training AAROM = active-assisted range of motion, ADL = activity of daily living, AROM = active range of motion, PROM = passive range of motion, ER = external rotation, IR = internal rotation, ROM= Range of Motion G/H = glenohumeral Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 7

  8. Rehabilitation Protocol for Small to Moderate Rotator Cuff Tear: Summary Table Post –op Phase/Goals Range of Motion Days 1 - 7 0 – 6 Weeks Goals : Protection of surgical site Gradual increase of passive range of motion Decrease pain and inflammation Maintain full C-spine, elbow, wrist and hand motions Re-establish dynamic scapular stability Participate in ADLs while protecting repair Scaption: 90 ˚ IR: ER 45 ˚ Therapeutic Exercise Precautions Protective Phase -Wear sling during the day and at night -Remove sling for showering/bathing -Remove sling 4 to 5 times per day for gentle elbow, forearm, wrist and finger exercises -Ball squeezing exercises -Neck Exercises -Ice for pain and inflammation 20 minutes as needed, best to allow 2 hours between applications -Pendulum exercises if advised by surgeon, depending on the quality of the repair -Scapular retraction and depression -Continue above -Pendulum exercises -Ice as needed -Painfree PROM by therapist in supine flexion, scaption, internal and external rotation (in scapular plane) -Maintain arm in abduction sling/brace until end of week 6 or as advised by surgeon -Wear sling at night while sleeping -Remove sling/brace only for exercise or showering -Avoid excessive stretching -Avoid sudden motions -Avoid lying on operated arm -Avoid overstressing the healing tissues -Do not use arm beyond hand to mouth -Do not lift elbow away from body -Do not lift objects -Do not reach arm behind back -Do not support body weight on hands -Keep elbow at side with all activities including use of computer Weeks 2-4 PROM Goals: Flexion: 100 ˚ 45 ˚ Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 8

  9. Weeks 4 - 6 -Avoid superior humeral head migration or scapular hiking (shrug sign) with all motion -Progress PROM with goal of full painfree PROM by end of 6 weeks Continue program above Manual: -Gentle scapular, glenohumeral joint mobilization as indicated to progress PROM -Soft Tissue Mobilization as indicated -Upper trapezius stretching -Ball rolling on table with elbow below shoulder level -Initiate AAROM with dowel in supine --- Flexion to 145˚ -AAROM overhead pulleys flexion/scaption -Submaximal pain free isometrics with flexed elbow: Flex/Ext/Abd/IR/ER -General conditioning while protecting shoulder (walking, stationary bike) at week 5 -Discontinue brace or sling at end of week 6 unless advised by surgeon -Utilize sling if needed for protection in crowds -Gradual increase in functional activity while avoiding superior humeral head migration -Resume driving if advised by surgeon Criteria for Progression to Phase II Painfree PROM Flexion to Flexion to ≥125° Passive ER in scapular plane to ≥ 75° (if uninvolved shoulder PROM >80°) Passive IR in scapular plane to ≥ 75° (if uninvolved shoulder PROM >80°) Passive abduction ≥ 120° Progress to active elevation only when patient can elevate cleanly without humeral head migration or scapular hiking. Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 9

  10. Phase II Intermediate Phase Active Motion and Early Strengthening Weeks 6 - 10 PROM full and pain free by week 10 Decrease pain and inflammation Gradual increase in strength Dynamic scapular stabilization Optimize neuromuscular control Criteria for Progression to Phase III -Progress painfree PROM -Start AAROM to tolerance -AAROM behind back -Continue Program above -Soft tissue mobilization over healed incision -Gentle scapular/glenohumeral joint mobilization as indicated to regain full painfree PROM -Dynamic shoulder stabilization in supine to facilitate functional movement -Initiate deloaded /MET pullies -Initiate AAROM -Sidelying flexion and scaption -Active ER to 30° – 40° -Closed kinetic chain activities Ball on wall Wall pushups -Initiate strengthening program NO SHRUG! -Resisted IR/ER with tubing (axillary roll to avoid fully adducted position) -Isotonic strengthening of scapular stabilizers -Initiate prone strengthening to neutral, avoid activation of upper trapezius -Resisted elbow flexion and extension -No excessive movements behind back -Avoid sudden, jerking motions -No lifting greater than 5# -Keep load close to body -Resume light functional activities -Avoid heavy housework/yardwork -No vacuuming or shoveling Full pain free AROM, NO SHRUG! Dynamic shoulder stability Gradual restoration of shoulder strength, power and endurance Optimize neuromuscular control Gradual return to functional activities Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 10

  11. Phase III Early Strengthening Weeks 10 – 12 Goals Restoration of full and pain free AROM Gradual Return to functional activities Gradual increase in strength Optimize neuromuscular control Criteria to D/C PT AAROM = active-assisted range of motion, ADL = activity of daily living, AROM = active range of motion, PROM = passive range of motion, ER = external rotation, IR = internal rotation, ROM= Range of Motion G/H = glenohumeral Progress AROM to tolerance -Continue soft tissue mobilization over healed incision -More aggressive scapular/glenohumeral joint mobilization as indicated to regain full pain free PROM/AROM -Initiate resistive exercise gradually -Sidelying ER/IR -Standing scaption, flexion and abduction -Progress closed kinetic chain exercises -Trunk and lower body strengthening (especially in throwing athletes) Precautions: -No excessive movements behind back -Avoid sudden, jerking motions -No overhead lifting -Resume normal daily activities with caution -Check with surgeon re: return to sports and lifting restrictions -Typical return to sports is 6 to 8 months with clearance of surgeon Full painfree AROM with good mechanics unless patient requires further vocational or sport training Small to Moderate RCT, App by M. Lemos, MD, Comp by Compiled by K. Gagnon, PT, K. Keen, PT, E. Lang, DPT 8_2013 11