Rotator Cuff Tendonitis/Impingement Rehabilitation Protocol - PDF Document

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  1. Laith M. Jazrawi, MD Laith M. Jazrawi, MD Associate  Professor  of  Orthopaedics Chief  -­‐  Division  of  Sports  Medicine   Tel:  (212)  598-­‐6784       Rotator Cuff Tendonitis/Impingement Rehabilitation Protocol                                                                                                                                                                                                                                                                   Name:  ____________________________________________________________                            Date:  ___________________________________     Diagnosis:  _______________________________________________________                            Date  of  Surgery:  ______________________     INTRODUCTION:     • Impingement  is  a  chronic  inflammatory  process  produced  as  the  Rotator  Cuff  Muscles  (supraspinatus,   infraspinatus,  teres  major,  and  subscapularis)  and  the  Subdeltoid  Bursa  are  pinched  against  the   coracoacromial  ligament  and  the  anterior  acromion  when  the  arm  is  raised  above  90  degrees.  The   supraspinatus/infraspinatus  portion  of  the  rotator  cuff  is  the  most  common  area  of  impingement.  This   syndrome  is  commonly  seen  in  throwing  sports,  racquet  sports,  and  in  swimmers;  but  can  be  present  in   anyone  who  uses  their  arm  repetitively  in  a  position  over  90  degrees  of  elevation  .The  protocol  serves  as  a   guide  to  attain  maximal  function  in  a  minimal  time  period.  This  systematic  approach  allows  specific  goals   and  criteria  to  be  met  and  ensures  the  safe  progression  of  the  rehabilitation  process.     ACUTE  PHASE  –MAXIMAL  PROTECTION   • Goals:   oRelieve  pain  and  swelling   oDecrease  inflammation   oRetard  muscle  atrophy   oMaintain/increase  flexibility   oActive  Rest:  the  elimination  of  any  activity  that  causes  an  increase  in  symptoms   • Range  of  Motion  Exercises   oPendulum  Exercises   oAAROM  –Limited  symptom  free  available  range   oRope  &  Pulley   § flexion   oL-­‐Bar   § Flexion   § Neutral  external  rotation   • Joint  Mobilizations   oInferior  and  posterior  glides  in  scapular  plane   • Modalities   oCryotherapy   oTENS   • Strengthening  Exercises   oIsometrics  –submaximal   oExternal/internal  rotation   oBiceps   oDeltoid  (anterior,  middle,  posterior)   • Patient  Education   oRegarding  activity,  pathology  and  avoidance  of  overhead  activity,  reaching,  and  lifting  activity   • Guidelines  for  Progression   oDecreases  pain  and/or  symptoms   oROM  increased   oPainful  arc  in  abduction  only   oMuscular  function  improved     SUBACUTE  PHASE  –MOTION  PHASE  

  2. Laith M. Jazrawi, MD Laith M. Jazrawi, MD Associate  Professor  of  Orthopaedics Chief  -­‐  Division  of  Sports  Medicine   Tel:  (212)  598-­‐6784       Goals   • oRe-­‐establish  non-­‐painful  ROM   oNormalize  arthrokinematics  of  shoulder  complex   oRetard  muscular  atrophy   Range  of  Motion   oRope  &  Pulley   § Flexion   § Abduction   oL-­‐Bar   § Flexion   § Abduction  (symptom  free  motion)   § External  rotation  in  45°  of  abduction,  progress  to  90°  of  abduction   § Internal  rotation  in  45°  of  abduction,  progress  to  90°  of  abduction   oInitiate  anterior  and  posterior  capsular  stretching   Joint  Mobilizations   oInferior,  anterior,  and  posterior  glides   Modalities   oCryotherapy   oUltrasound/phonophoresis   Strengthening  Exercises   oContinue  isometrics  exercises   oInitiate  scapulothoracic  strengthening  exercises   oInitiate  neuromuscular  control  exercises   Guidelines  for  Progression   oBegin  to  incorporate  intermediate  strengthening  exercises  as:   § Pain/symptoms  decrease   § AAROM  normalizes   § Muscular  strength  improves   • • • • •   INTERMEDIATE  STRENGTHENING  PHASE   • Goals   oNormalized  ROM   oSymptom-­‐free  normal  activities   oImproved  muscular  performance   • Range  of  Motion   oAggressive  L-­‐Bar  AAROM  all  planes   oContinue  self-­‐capsular  stretching  (anterior/posterior)   • Strengthening  Exercises   oInitiate  isotonic  dumbbell  program   § Sidelying  neutral   • internal/external  rotation   § Prone   • extension   • horizontal  abduction   § Standing   • flexion  to  90°   • abduction  to  90°   oInitiate  serratus  exercises   § Wall  push-­‐ups   oInitiate  tubing  progression  in  slight  abduction  for  internal/external  rotation   • Guidelines  for  Progression  

  3. Laith M. Jazrawi, MD Laith M. Jazrawi, MD Associate  Professor  of  Orthopaedics Chief  -­‐  Division  of  Sports  Medicine   Tel:  (212)  598-­‐6784       oFull  non-­‐painful  ROM   oNo  pain/tenderness   o70%  Contralateral  strength     DYNAMIC  ADVANCED  STRENGTHENING  PHASE   • Goals:   oIncrease  strength,  power,  endurance   oIncrease  neuromuscular  control   • Strengthening  Exercises   oInitiate  Thrower’s  Ten  Exercise  Program  (if  overhead  athlete)   oIsokinetics   § Progress  from  modified  neutral  to  90/90  position  as  tolerated   oInitiate  plyometric  exercises  (Late  in  phase)   • Guidelines  for  Progression   oFull  non-­‐painful  ROM   oNo  pain  or  tenderness   oIsokinetic  test  fulfills  criteria   oSatisfactory  clinical  exam     RETURN  TO  ACTIVITY  PHASE   • Goals   oUnrestricted  symptom-­‐free  activity   • Initiate  Interval  Program   oThrowing   oTennis   oGolf   • Maintenance  Exercise  Program   oFlexibility  Exercises   § L-­‐Bar   • • • oIsotonic  exercises   § Supraspinatus   § Prone  extension   § Prone  horizontal  abduction   oThera-­‐tubing  exercises   § Internal/external  rotation   § Neutral  or  90/90  position   oSerratus  push-­‐ups   oInterval  throwing  phase  II  for  pitchers       Comments:       Frequency:    ______  times  per  week             Signature:  _____________________________________________________                                                Date:  ___________________________   Flexion   External  rotation   Self-­‐capsular  stretches     Duration:  ________  weeks