Therapy Protocols
I have taken excerpts from the book I
co-authored..."Burkhart's
View of the Shoulder: A Cowboy's Guide to Advanced Shoulder
Arthroscopy"
to describe several therapy protocols.
REHABILITATION AFTER ARTHROSCOPIC ROTATOR CUFF
REPAIR
The
senior author (SSB) has long believed that early range of
motion after rotator cuff repair is contraindicated in most
cases. This belief was based on personal observations
of intraoperative knot failure during open rotator cuff
repair when the patient had his shoulder taken through a
range of motion. In fact, at the time of open repair,
if the surgeon takes the patient’s arm up to 180 degrees of
elevation six or seven times in a row, the last throw of
the knot will typically come untied due to generation of
large torsional forces within the knot. If the arm is
then taken through another six or seven overhead
elevations, the second throw of the knot will come untied
and the knot will sequentially fail in this manner.
Furthermore, if one looks arthroscopically at a single-row
repair in which the rotator cuff is nicely apposed to the
rotator cuff footprint with the arm at the side, and then
the surgeon brings the arm into overhead elevation, he will
see that the medial portion of the footprint lifts off the
prepared greater tuberosity bone bed. If this is
occurring repetitively, there is no chance for healing at
this interface due to the continual motion between tendon
and bone. Therefore, we have generally attempted to
immobilize our rotator cuff repairs for the first six weeks
after surgery in order to achieve secure biologic healing
before starting range of motion.
More recently, there has been additional basic science
information suggesting that immobilization is beneficial to
rotator cuff healing. Soslowsky and his associates
have presented information that there are significant
increases in strain at the rotator cuff repaired margin if
the arm is brought passively into the overhead position
(personal communication).
A recent study by Gerber and associates showed that, with
early passive motion after rotator cuff repair, the
collagen fibers tended to align in a rather random fashion,
whereas with immobilization for several weeks the collagen
fibers aligned in a parallel array, giving stronger
resistance to applied forces (1). Based on the above
studies, it seems evident that a period of immobilization
to allow healing of the rotator cuff to bone would be
beneficial.
One of the most appealing features of shoulder
arthroscopy in comparison to open surgery is the fact that
there is very little scarring between the deltoid and
underlying tissues with the arthroscopic approach.
For that reason, immobilization for six weeks can be
carried out without the rather extreme stiffness that would
occur with a similar period of immobilization after open
repair.
In general, following arthroscopic rotator cuff
repair, our rehabilitation protocol is as
follows:
1.
The
first 6 weeks – The patient wears a sling and does passive
external rotation stretches as tolerated, and the patient
is encouraged to achieve at least 45 degrees of external
rotation (Fig. 1). The exception to this protocol is
in the patient with a subscapularis repair. If the
subscapularis is repaired as a part of the overall cuff
repair, external rotation is restricted to 0 degrees for
the first six weeks, and then is progressed as tolerated
after that.
2.
Week
seven through twelve – The patient begins passive elevation
as tolerated using a rope and pulley (Fig. 2) as well as
supine overhead stretches using the opposite arm (Fig.
3). The patient also continues with passive external
rotation stretches.
3.
Thirteenth
week and thereafter – The patient begins a strengthening
program using Thera-Band with our standard “four-pack”
exercises (Fig. 4). The four-pack includes resisted
external rotation, resisted internal rotation, one-armed
row, and biceps curl. The patient starts with the
smallest diameter Thera-Band, which is a red Thera-Band,
and is encouraged to do four sets of ten repetitions twice
a day. The patient progresses up to the green
Thera-Band and then the blue Thera-Band as tolerated.
4.
In the
case of a revision rotator cuff repair or repair of a
rotator cuff tear that is greater than 5 cm in diameter, we
do not begin strengthening until seventeen weeks (4 months)
postop. The reason for this more extended period of
immobilization is that we believe that more time is needed
for vascular ingrowth in these massive and revision repairs
than in smaller repairs to achieve strong mechanical
healing before stressing this repair.
5.
Six
months and thereafter -- The patient may resume full
unrestricted activities if this is a primary repair that is
less than 5 cm in diameter. If it is a revision
repair or has a diameter greater than 5 cm, then we have
the patient wait until 12 months postop to resume full
unrestricted activities, which would include golf or
overhead sports.
Currently,
there are two exceptions to the initial six week period of
immobilization that we employ in our practice. The
first exception is the patient with calcific
tendinitis. We have observed that such patients are
likely to develop rather profound chemical synovitis and
chemical bursitis from the calcific deposits after the
surgery, and if early stretching is not instituted they
tend to become very stiff postoperatively. Therefore,
we start immediate postoperative stretching, including
passive elevation with a rope and pulley as well as passive
external and internal rotation. The other exception
is the patient who has a small rotator cuff tear (less than
3 cm diameter) in association with a SLAP lesion that is
repaired at the same time. We have found in our
practice that this combination is also prone to stiffness
if early passive stretching is not begun, so we now start
immediate passive forward elevation as well as passive
external and internal rotation. In general, these
small rotator cuff tears are amenable to double row
fixation and we have a great deal of confidence in starting
early passive range of motion because of the high fixation
strength of this double row repair.
In general, for all categories of rotator cuff tear,
internal rotation stretching is begun at six weeks postop
but is not particularly emphasized. We simply have
the patient begin to stretch the hand up behind the back as
much as possible, and then do a reverse rope and pulley
stretch beginning at about eight to ten weeks postop.
Typically, restoration of internal rotation lags behind the
restoration of the other ranges of motion.
REHABILITATION AFTER ARTHROSCOPIC SLAP
REPAIR.
After
SLAP repair, the patient wears a sling for three
weeks. During that three-week period, the patient is
urged to perform external rotation stretches as far as
possible, trying to match the external rotation between the
operated arm and the unoperated arm by the end of four
weeks. Sleeper stretches (four sets of ten) are
performed twice a day (Fig. 5). After three weeks,
the sling is discontinued. At that point, the patient
begins overhead stretching and continues with passive
external rotation stretching. At 6 weeks postop,
Thera-Band strengthening is begun using the same four-pack
program as described above under rotator cuff
rehabilitation. However, in most cases, resisted
contraction of the biceps at six weeks postop will still be
a bit painful due to repair of the SLAP lesion at the
biceps root. If there is pain with resisted forward
flexion of the arm at six weeks postop, we delay the biceps
curl until eight weeks postop. At eight weeks,
closed-chain scapular control exercises are also begun
(Fig. 6) as well as open-chain scapular strengthening (Fig.
7). The low row (Fig. 8) is particularly good for
strengthening scapular retractors.
At three months postop, the patient may begin working out
with strengthening in the gym. If he is a baseball
player, he may begin to lob a baseball and initiate some
slow throwing motions, gradually progressing to an interval
throwing program beginning at four months postop.
Baseball players will usually need to include pectoralis
minor stretches as a part of their regimen (Fig. 9) (Table
I & II). At seven months postop, the patient may
return to full unrestricted activities, including all
overhead sports activities.
If the patient has had multiple structures repaired (for
example, combined rotator cuff and SLAP repairs), then we
tailor our rehabilitation program toward the repaired
tissues that require the longest period of immobilization
for healing. For example, with a combined SLAP repair
and rotator cuff repair, we would not begin strengthening
until twelve weeks postop in order to allow for complete
healing of the rotator cuff.
REHABILITATION AFTER ARTHROSCOPIC ANTERIOR INSTABILITY
REPAIR (Bankart)
1.
Weeks
one through four – the patient wears a sling full time and
is encouraged to externally rotate the arm only to 0
degrees (the straight-ahead position).
2.
After
four weeks – the sling is discontinued and the patient
begins overhead stretching using a rope and pulley.
3.
After
six weeks – the patient begins passive external rotation
stretching with a goal of having one-half the amount of
external rotation that is present on the opposite (normal)
side by the end of twelve weeks postop. Thera-Band
strengthening is also begun after six weeks, using the same
4-pack exercise protocol as described in the section above
on rotator cuff rehabilitation.
4.
Three
months postop – the patient may begin working out with
weights in the gym.
5.
Six
months postop – the patient is released to full activities
including contact sports.
In the
event of significant bone deficiency in which a Latarjet
procedure is performed, we tend to go a bit slower on
mobilization in order to allow full healing of the coracoid
bone graft. Therefore, after the Latarjet procedure,
we keep the patient in a sling for six weeks, allowing
external rotation only to 0 degrees. At the end of
six weeks, the patient begins overhead stretching and
external rotation stretching. Strengthening is
delayed until three months postop, to allow secure healing
of the bone graft as well as full healing of the upper
subscapularis tendon (due to the fact that the upper half
of the subscapularis is taken down from its insertion
during for the exposure in the Latarjet procedure).
At four months postop, the patient may begin working out in
the gym, and at six months postop, full unrestricted
activities are allowed, assuming that the bone graft is
consolidated.
REHABILITATION AFTER ARTHROSCOPIC POSTERIOR
INSTABILITY REPAIR
The sequence of rehabilitation after arthroscopic posterior instability repair is essentially analogous to that for anterior instability repair. The patient is kept in a sling for 4 weeks. During that time, he is allowed passive external rotation as tolerated but no passive internal rotation. The pillow splint is placed with the large bolster of the pillow anteriorly to keep the arm at approximately 10 degrees of internal rotation, which is closer to the neutral position than we allow during the first four weeks after anterior instability repairs. At four weeks postop the sling is discontinued and overhead stretching is begun along with external rotation stretching. Specific internal rotation stretching is not done. We simply allow the patient to gradually regain internal rotation as the overall shoulder rehabilitation progresses. At three months postop, the patient may begin working out in the gym, being careful to avoid the “hands-together” bench press. With the hands located further apart on the bar during the bench press, the force transmission to the shoulder is more in line with the glenoid, protecting the repair. At six months postop, the patient may return to full unrestricted activities including contact sports.