Management - Southern Health NHS Foundation Progression to functional activities ... Progression...

Treatment

09/07/2012 Treatment of Rotator Cuff Tear, A. Manek 1

Management

�Surgery�Rotator Cuff Rehabiliation�Anterior Deltoid Re-education


Indications for surgery/ onwardreferral

�Acute symptomatic tears in people <65 years due torecent trauma

�6/12 Unsuccessful trial of non-operative treatmentincluding steroid injection

�Diagnostic uncertainty�Neurological lesion� Infection


Operative Treatment�Arthroscopic Evaluation

(can often be combined with treatment)�Debridement Repair of partial thickness tear� Repair of small full-thickness tears

�Open Repair� In presence of full thickness tear and muscle retraction� Poor tissue quality�Weak bones


Rotator Cuff Rehabilitation

1. Relative Rest / unloading2. Strength Rehabilitation3. Return to Function


1) Relative Rest / unloading�Decrease Pain and inflammation� Medication (NSAID’s, steroid injection)� Relative rest/ movement modification

�Restoration and maintenance of ROM� Passive movements / mobilisations� Self-assisted exercises (wall-slides, stick, opp. hand)� Pendular exercises (no pain)� Gym ball� Reduce Atrophy� Scapular stabilisers, elbow/wrist, lower limbs


2) Strength Rehabilitation�Consider starting when pain only during movement� Increase Muscle Strength and Coordination�Exercise in pain free range and gradually increase� IR much later in rehab than ER�Consider:

� Standing, prone, side lying� PNF patterns� Increase number of repetitions before increasing weight


3) Return to Function�Progression to functional activities�Restoration of sensory-motor control

� Closed-chain exercises(Wall push-ups, push-ups, wobble board, ball(s))

�Open-chain exercises(catch ball, throw ball to targets, bounce ball, throwball with resistance tubing on arm)


Anterior Deltoid Re-education�Research was sparked by the observation that some

patients with massive rotator cuff tears presentedasymptomatic

�Wirth et al (1997) mentioned that “The anteriordeltoid is the most important muscle of the shouldergirdle, and special emphasis must be placed onstrengthening of this structure as decreased anteriordeltoid strength greatly limits function.”


Research / Evidence

1. Ainsworth R (2006) Physiotherapy rehabilitationin patients with massive, irreparable rotator cufftears. Musculoskeletal Care 4: 140-151.

2. Levy O et al (2008) The role of anterior deltoidre-education in patients with massiveirreparable degenerative rotator cuff tears.Reading Shoulder Unit, Berkshire Hospital.


Ainsworth (2006)�Pilot study (10 patients)�Evaluating a rehabilitation programme (=Torbay

Programme) which included anterior deltoidstrengthening and functional rehabilitation

�Patients attended ½ hour weekly for 4 weeks, then at2-3 weekly intervals with progressing home exercises

�Outcome evaluation after 12 weeks�Outcome measure was the Oxford Shoulder Disability

Questionnaire (OSDQ)� All 10 patients had improved


The Torbay Programme

�Patient education�Posture correction�Re-education of muscle recruitment�Strengthening (mainly anterior deltoid)�Stretching� Improving proprioception�Adaptation


Levy et al (2008)

�Prospective study (17 patients)� The patients were treated with an anterior deltoid

rehabilitation programme�Patients were given standard detailed instruction and

an illustrated guide�Patients were reviewed after a minimum of 9 months

� 14 patients regained a good ROM and did not need anypain medication

� 3patients did not have adequate improvement


Reading Shoulder UnitAnterior Deltoid Exercises

Advice for Patients with Massive Rotator Cuff Tears�Written patient education�Exercises must be done for at least 12 weeks,

3 to 5 times a day�Exercises:

�Gentle pendulum movement for about 5 minutes� Progression of lying down exercises� Progression of same exercises in sitting� Progression of same exercises in standing

�Stop exercising if your pain increases or you feelunwell

�You will be reviewed at 6 and 12 weeks09/07/2012 Treatment of Rotator Cuff Tear, A. Manek 15

Supine I


Supine II


Supine III


Sitting


Standing


Summary�Surgery�Rotator Cuff Rehabiliation�Anterior Deltoid Re-education

� Evidence based on small studies�Widely accepted and used� Seems to work� “Eccentric Anterior Deltoid Training” is a phrase

commonly used but no evidence for using onlyeccentric contractions


References� Ainsworth R (2006) Physiotherapy rehabilitation in patients with massive, irreparable

rotator cuff tears. Musculoskeletal Care 4: 140-151.� Ainsworth R, Lewis J (2007) Exercise therapy for the conservative management of full

thickness tears of the rotator cuff: a systematic review. Br J Sports Med; 41: 200-210.� Donatelli RA (2004) Physical Therapy of the Shoulder. Churchill Livingstone.� Garg S et al (2010) Managing rotator cuff disorders. Arthritis Research UK, Reports on

Rheumatic Diseases, Series 6, Topical Reviews No 7.� Levy O et al (2008) The role of anterior deltoid re-education in patients with massive

irreparable degenerative rotator cuff tears. Reading Shoulder Unit, Berkshire Hospital.� Lewis J (2009) The Shoulder, Theory and Practice, Course notes, Health Education

Seminars.� Malanga GA et al (2009) Rotator cuff injury. Emedicine.medscape.com.� Wirth MA et al (1997) Non-opertative management of full-thickness tears of the rotator

cuff. Orthopaedic Clinics of North America, Vol 28, Issue 1.


Management - Southern Health NHS Foundation Progression to functional activities ... Progression...

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Transcript of Management - Southern Health NHS Foundation Progression to functional activities ... ￿Progression...

Management - Southern Health NHS Foundation Progression to functional activities ... Progression...

Transcript of Management - Southern Health NHS Foundation Progression to functional activities ... Progression...