Surgery-Specific Rotator Cuff Rehabilitation ProgramWhen it comes to rotator cuff tears and repairs, things are shifting in the orthopedic world. Surgeons are gradually moving from an all-open incision procedure to an all-closed arthroscopic operation. And along with it, physical therapists (PTs) are modifying the rehab program to match each patient's needs.
Patient goals in having a rotator cuff repair are to get rid of pain, increase motion and strength, and improve function. The surgeon's goals are to gain high fixation strength (tendon-to-bone), reduce the gap between the torn tendon and bone, and restore mechanical stability of the shoulder. That means there has to be good healing of the tendon-to-bone that has the ability to hold up under repetitive load and force.
Results of surgery depend on two things: good surgical repair and a surgery-specific rotator cuff rehab program. That means more than ever, PTs and orthopedic surgeons must be communicating with one another about what kind of surgery was done, what the patient needs, and the best way to approach functional rehabilitation.
So, in this article, PTs and surgeons present information from both sides. The surgeons describe and discuss the three most likely types of rotator cuff repair techniques. These include 1) open rotator cuff repair, 2) mini-open rotator cuff repair, and 3) all-arthroscopic rotator cuff repair. A step-by-step summary of each procedure with photos of the incision site and size are included.
The open-incision repair is used most often for large rotator cuff tears that leave the patient with significant scarring and adhesions in and around the joint. The torn tendon has retracted or pulled back into the soft tissues and is not easily retrieved or repaired arthroscopically.
The major downside of this procedure is postoperative pain and the loss of muscle function because the deltoid muscle is cut to gain access to the damage. The pain can especially hinder progress in physical therapy. Slower recovery time is required.
The mini-open repair uses arthroscopy to avoid cutting the deltoid muscle. The incision is slightly longer than with all-arthroscopic repair but shorter than the full open-repair incision. The surgeon can split the deltoid rather than cut it and insert the scope down between the two halves of the muscle. The repair procedure can be completed arthroscopically from there.
Studies show that the results of the mini-open repair are similar to an open repair with up to 88 per cent of patients getting good-to-excellent long-term results. And finally, the all-arthroscopic repair is presented with some concerns about the procedure.
Surgeons say that there are fewer cases of stiffness and infection with this surgical approach. But there aren't very many long-term studies to show how useful this method may be. And surgeons are still debating the best way to reattach the tendon to the bone arthroscopically.
Most recently, a new technique called double-row sutures has been developed. This technique secures a larger area of the tendon down to the bone. This repair method may make it easier to begin rehab earlier and move it along faster. Double-row sutures may help with the need to move the joint to avoid stiffness without disrupting the healing process.
But the bulk of this article is focused on the postoperative rehabilitation program following surgical treatment of rotator cuff tears. Patient education is important. Healing is slow. The patient must protect the repair site for at least 12 weeks. A special splint called an abduction pillow brace is used. The device fits under the arm. It is designed to place the shoulder in a protective position that avoids strain on the healing rotator cuff.
The authors point out 12 important factors that affect the postoperative rehab program. These include characteristics of the tear (size, location, tissue quality) and many surgical factors (approach, timing, and fixation method). Patient characteristics and access to care can make a big difference. For example, smokers in poor health have greater risks for poor wound healing. Access to a supervised physical therapy versus an independent home program can affect the final outcomes, too.
Therapists know that patients who have an open incision approach must be treated differently than an all-arthroscopic procedure. The difference comes back to the fact that the deltoid muscle is cut in a traditional open rotator cuff repair. For example, the patient must avoid contracting the deltoid muscle for up to eight weeks. It takes a full month longer for patients with an open-incision to regain their previous level of activity compared with even the mini-open repair.
The rehab program moves along at a pace that is directly linked with the size of the tear. Larger tears with more tissue damage and greater retraction of the tendon take longer to rehab. A more conservative approach is used.
The surgeon must let the therapist know the condition of the tear at the time of the surgery. Where was it located? How large was the tear and in which direction? Was it L-shaped, U-shaped, or crescent-shaped? What fixation method did the surgeon use to repair the tear (single-row sutures, double-row sutures, suture bridge)? The rehab timeline can then be matched to small, medium, and large tears. This is called surgery-specific rehabilitation.
If more than one part of the rotator cuff is damaged, then more protection and a longer recovery period are allowed. The therapist must know if the anterior (front of the) rotator cuff, the posterior (back of the) rotator cuff, or both were damaged. This information is used to restrict or encourage direction and degree of shoulder range-of-motion and strengthening.
Patients with traumatic (as opposed to wear and tear or degenerative) injuries tend to develop more stiffness postoperatively if they aren't treated more aggressively right from the start. Early repairs after the injury can be moved through therapy more rapidly. But patients with fair-to-poor quality of tissue require a slower, more cautious approach.
Other factors therapists take into consideration when planning and carrying out a rehab program include which arm was affected (dominant versus nondominant), general health, smoking history, work status, and patient goals for return to sports or recreational activities.
The physical therapists involved in co-authoring this article present some specific guidelines for therapists working with patients who have had a rotator cuff tear repair. Tips on how to introduce range-of-motion exercises to avoid stiffness without endangering the repair are offered. The same is done for muscle retraining and strengthening exercises. Some of the suggestions were based on previous studies published. Others provided are the result of years of clinical experience.
Rhythmic stabilization exercises are used to activate the rotator cuff muscles but without actually strengthening the muscles. This is a safe and effective way to restore dynamic stabilization of the joint. Positioning and amount of force needed to achieve this result are described.
The authors also provide four very nice tables in the appendix to guide the therapist in planning an appropriate rotator cuff repair rehabilitation program. As already mentioned, the first table shows the patient, surgical, and physician factors affecting the postoperative rehab program.
The next two tables outline specific precautions, goals, and activities allowed day-by-day and week-by-week for small-to-medium tears and also for medium-to-large tears. Four phases are included from immediately after surgery all the way up to returning the patient to full work and sports activities.
And finally, range-of-motion and strengthening exercises with diagrams and descriptions are provided. These can be given to patients with space left for the therapist to record number of repetitions and how long to hold each exercise.
Neil S. Ghodadra, MD, et al. Open, Mini-open, and All-Arthroscopic Rotator Cuff Repair Surgery: Indications and Implications for Rehabilitation. In Journal of Orthopaedic & Sports Physical Therapy. February 2009. Vol. 39. No. 1. Pp. 81-89; A1-A6.
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