Rotator+Cuff+Repair

**Introduction**
toc The following is a web page designed to give a helpful overview of the factors associated with a rotator cuff tear. Although it is not all-inclusive, it is designed to be a quick clinical resource. Useful links to additional articles are provided for more in-depth information.

**Anatomy**


The rotator cuff is a combination of four muscles that stabilize the glenohumeral joint as well as assist in movement of the humerus. The muscles that make up the rotator cuff and their respective origin, insertion, and action are as follows:

Here is a picture of a lateral view of the shoulder, showing the tendons and their location around the capsule.
 * Muscle || Origin || Insertion || Action ||
 * Supraspinatous || Supraspinous Fossa || Greater tubercle of humerus (superior facet) || Abduction and External Rotation ||
 * Infraspinatous || Infraspinous Fossa || Greater tubercle of humerus (middle facet) || External Rotation ||
 * Teres Minor || Lateral border of the scapula || Greater tubercle of humerus (inferior facet) || External Rotation ||
 * Subscapularis || Subscapularis Fossa || Lesser tubercle of humerus || Internal Rotation ||

**Biomechanics**

 * Supraspinatus- Initiates abduction and is more active at lower levels to prevent the humeral head from solely translating superiorly, due to motion of the deltoid. If the supraspinatus is torn, the deltoid takes over as the main elevator of the arm. This can lead to impingement if the supraspinatus is not activating to control the humeral head.
 * Infraspinatus- An external rotator acts primarily when the arm is in neutral. Its attachment allows it to be a stabilizer of the posterior cuff and prevents anterior and superior displacement of the humerus
 * Teres Minor- An external rotator that is more active when the arm is abducted 90 degrees. The teres minor also works with the infraspinatous to stabilize the posterior capsule.
 * Subscapularis- The subscapularis is the primary internal rotator of the cuff. It also assists in abduction from 60 to 90 degrees, where it then drops off and allows the mid trap to take over.

Force Couples:
 * 1) Deltoid and Supraspinatus- work together to accomplish abduction of the humerus.
 * 2) Subscapularious and Infraspinatus- work together to overall stabilize and center the humeral head.

The tendons of the rotator cuff muscles come together to form a unified sheath around the glenohumeral joint, which is why it can be so difficult to isolate the action and to target one specific muscle of the cuff.

** Mechanism of injury **
The mechanism of injury (MOI) varies in rotator cuff cases, but can usually be contributed to repetitive stress, impingement (anatomical structure), and trauma. Repetitive stress such as sports or work related motions (throwing, swimming, overhead tasks) can cause degeneration of the muscles of the rotator cuff. As the musculature degenerates and the joint becomes more unstable, tears are much more likely to occur. Other non sports and non repetition related injuries can be contributed to impingement. The acromion is directly over the supraspinatus, which puts it in a vulnerable place for impingement. The type/shape of ones acromion (flat, curved, or hooked) can put them at a greater risk for impingement, and thus, a potential supraspinatus tear. Tears that result from trauma are usually due to collisions in sports or other accidents. Typically, older adults suffer from tears due to overuse and degeneration and younger people are more likely to suffer a tear due to trauma.



**Signs and Symptoms**

 * Will be indicated by physical exam, which should include visual inspection, palpation, range of motion, pain provocation testing, resisted strength testing, neurologic screening, and screening of the C-spine.

Some rotator cuff tears are asymptomatic. The reasoning for this is still unknown although research is looking into the tear characteristics as a potential reason. For Symptomatic tears: //__* **- cardinal findings of tear**__//
 * *limited AROM
 * *weakness
 * pain in the affected shoulder during active movement
 * shoulder hike
 * possible visible muscle wasting in the supraspinous and infraspinous fossa
 * changes in symmetry with visual inspection of shoulders bilaterally
 * Tenderness to palpation over rotator cuff muscle insertions
 * Pain at night when sleeping on affected side
 * interference with activities of daily living due to pain and weakness

Testing results: (+) - Drop arm test (+) - Empty can test (+) - Lag sign in abduction (Arm positioned in 90 deg flexion, 90 deg abduction-- PT releases wrist and elbow and arm drops 10 deg) (+) - Neer's (pain with flexion 70-120 degrees: abnormal test result) (+) - Hawkins-Kennedy
 * Supraspinatus: weakness with arm elevation
 * Infraspinatus: weakness with external rotation
 * Teres Minor: weakness with external rotation
 * Subscapularis: weakness with internal rotation and extension
 * If arm moves into IR when wrist released it is more infraspinatus
 * If arm drops when elbow released it is more supraspinatus

NOTE: acute, complete rotator cuff tears typically present with more weakness and disability than chronic, complete rotator cuff tears.

**Treatment and Interventions**

 * Conservative**
 * Conservative treatment is used in cases where surgery is not indicated due to the patient's condition and the size of the tear. This approach is similar to surgical in that it focuses on pain management, scapular and glenohumeral stabilization, progressive ROM and strengthening. Many of the interventions and exercises will be the same as those used in surgical protocols, but conservative treatment does not include the active and passive ROM limitations that are common after surgery to allow healing.
 * Biomechanical dysfunctions that may have lead to the degeneration of the rotator cuff muscles need to be addressed to avoid reinjury.
 * Some modalities used for conservative treatment include ultrasound, phonophoresis and iontophoresis for pain and/or inflammation.
 * Treatment duration will likely be shorter than that of post-op rehabilitation, due to decreased severity of injury and not needing additional healing time after surgery.

media type="youtube" key="6DOKLLIss-8" height="315" width="420"
 * Surgical Techniques**
 * **Open**: This approach is less common today but used for massive tears. It requires the deltoid to be detached from anterior acromion and an incision that is 4-7 cm in length. This results in possible complications such as post surgical deltoid dysfunction and higher levels of pain. Since the deltoid was detached no active contractions of the deltoid are allowed for 6-8 weeks. This means no AAROM or AROM post-surgery for several weeks. With just passive ROM the rehab process is slower than the other techniques. Different reported success rates are from 80-90% reporting a good or excellent outcome.
 * **Mini-open**: This technique is mostly arthroscopic with a smaller incision (2-4 cm) in deltoid. There is a quicker rehab process due to less damage and lower levels of post-op pain.
 * **Arthroscopic**: This is the newer technique which is fairly popular since there is minimal damage to deltoid. The muscle is not detached or disrupted except for the arthroscopic portals. This means there is generally less pain and lower chance for infection. Since this approach is newer there is limited long term outcome data.


 * Treatment duration**
 * Treatment after surgical repair is typically 12-16 weeks. Further physical therapy treatment may be needed up to 24 weeks for athletes returning to sport, or workers returning to a physically demanding job.


 * Factors that influence healing and rehab process:**
 * Size of tear
 * Tissue quality- amount of degeneration to the tendon and quality of tissue and blood supply to the area
 * Surgical technique- open, mini-open, or arthroscopic
 * Level of activity prior to surgery- patients who were more active before surgery will return to higher levels of function than those who weren't very active
 * Mechanism of injury- 95% of rotator cuff tears are from overuse and degeneration, 5% are related to traumatic injury


 * General Treatment Guidelines**
 * Protection- The patient will have a sling with an abduction pillow to decrease the strain on the tendon site
 * Motion- Passive motion in supine has least muscle activation so best approach for early ROM activities. Active motion restrictions are usually the following: IR and ER to 45 deg in 30-45 degrees of abduction; flexion less than 120 degrees
 * Strengthening-
 * Controlled isometrics in various angles- especially IR and ER
 * Rhythmic stabilization for cocontraction of muscles to improve dynamic stability of the GH joint.
 * Isotonics IR and ER in sidelying for best muscle activation.
 * Scapular strengthening for scapulohumeral rhythm and better positioning of the scapula to provide adequate subacromial space for rotator cuff.
 * Light resistance, high repetition

For additional protocols check out some of the article links provided in the Additional Resources section at the bottom of the page.
 * Protocol**

**Exercises** Literature demonstrates increased shoulder girdle muscle activation with the following exercises:
 * Supraspinatus
 * Full Can (Scaption with ER)
 * Prone Horizontal Abduction at 100° with ER (Y)
 * Infraspinatus/Teres Minor
 * Prone Horizontal Abduction at 90° with ER (T)
 * Side lying ER
 * Subscapularis
 * IR at 0°
 * IR at 90°
 * Deltoid
 * D1/D2 flexion
 * Flexion, Abduction, Scaption > 120°
 * Military press
 * Serratus Anterior
 * D1/D2 flexion
 * D2 Extension
 * Push-up plus sequence
 * Upper Trapezius
 * Shoulder shrug
 * Prone row
 * Middle Trapezius
 * Prone row
 * Shoulder Shrug
 * Lower Trapezius
 * Prone horizontal abduction at 135° and 90° (Y and T)
 * Prone row
 * Rhomboids/Levator Scapulae
 * Prone row
 * Prone horizontal abduction at 90° with ER (T)

For exercise handouts for a HEP check the links in the Additional Resources section at the bottom of the page.

Your can should be half-full, not half empty! Empty can (humeral abduction with IR) may result in: Both empty and full can detect injured supraspinatus tendon, recent literature suggests testing in full can position to decrease pain provocation.
 * Lack of clearance of greater tubercle from under acromion è decreased subacromial space è impingement
 * Increased tensile stress due to decreased abduction moment of supraspinatus è decreased mechanical advantage
 * Increased winging due to scapular IR/anterior tilt è decrease in subacromial space


 * Modalities**
 * **Ice:** It is recommended to ice the shoulder for 15 minutes 3-5 times per day during weeks 0-6, and 15 minutes 1-3 times per day during weeks for pain and inflammation.
 * **IFC:**IFC can be used in all post-op phases for inflammation and pain management. Discontinue as pain diminishes and continue to use ice for inflammation.
 * Settings for pain management: Quadripolar, 80-150 Hz, 125-250 microseconds for phase duration, treatment time 10-15 minutes
 * **NMES:**NMES has been suggested for increased force production of external rotators during rehabilitation. The use of NMES may be beneficial as an adjunct treatment for rotator cuff musculature recruitment during early strengthening phases.
 * Settings: Quad or bipolar, pulse duration of 300-600ms, on 10 seconds and off for 50 seconds, beat frequency between 35-85 pps (depends on goal of treatment: muscle re-education, atrophy reduction, or strengthening), duration of 10-15 minutes, incorporate active isometrics exercises



As rehab progresses patients who participate in sports may start functional activities that are sport-specific. These activities need to focus on encouraging proper body mechanics, include a warm-up and specific shoulder exercises (Throwers 10 Program- included in links below), be gradual in nature to prevent reinjury, and also incorporate the entire body. Other activities such as plyometrics, core strengthening, and cardiovascular exercises should be added as well. The table below is an interval throwing program for baseball. Each step should be completed 2 to 3 times (pain-free) before progressing to the next step. Look in the Additional Resources section for the link to an article that contains similar programs for Little League, tennis, and golf.
 * Return to Sport**



During rotator cuff rehabs, other issues could occur which could slow the progress of the patient's recovery.
 * Troubleshooting**
 * Cervical Spine- Patient may have some pain, stiffness, or general discomfort in the cervical spine area especially due to changes in movement patterns or from wearing the sling. Also cervical spine issues refer to the shoulder.
 * Thoracic Spine- Thoracic mobility affects shoulder mobility. Patients will need good posture to get the best ROM results so postural education and self-thoracic mobilization could be incorporated.
 * Scapulothoracic Joint- Scapular stabilization and positioning is very important to provide stability for upper extremity mobility. Activities that address scapular strengthening and proper scapulohumeral rhythm need to be included.


 * Alternative Treatments**
 * The Regenexx Procedure is an alternative treatment that can be used for rotator cuff tears, along with other conditions causing pain in the shoulder including shoulder tendinitis, tendinosis, arthritis and bursitis. This procedure consists of injecting stem cells, which as the website explains, helps to magnify the body's healing process. The Regenexx Procedure has been used in a couple professional athletes. More about this procedure can be found at the website listed below.

@http://www.regenexx.com/the-regenexx-procedures/shoulder-surgery-alternative/


 * Additional Resources:**
 * Ghodadra et al article has different protocols for small tears or large and massive tears. Also includes a good handout that could be used for HEP with the basic exercises commonly used for RTC rehab with pictures.
 * @http://shoulderelbowdoc.com/articles/open-mini-open-and-all-arthroscopic-rcr-sx-indications-and-implications-for-rehab.pdf
 * Reinold et al article has several different interval programs for return to sport after shoulder injuries. Some of the programs in the article are baseball, Little League, golf, and tennis.
 * @http://www.ithaca.edu/hshp/ess/AT/Articles%20&%20Documents/SMAT%20Journal%20Articles/Rehab%20&%20Modalities/Interval%20Sports%20Programs.pdf
 * The American Academy of Orthopaedic Surgeons provides an instructional handout for general rotator cuff and shoulder strengthening. This could be a useful tool for an illustrated home exercise program whether post-operative or conservative rehabilitation.
 * @http://orthoinfo.aaos.org/PDFs/Rehab_Shoulder_5.pdf
 * The Throwers 10 program is a common exercise program used for general strengthening and endurance for throwing athletes. It is often included in their warm-ups. This handout includes explanations and pictures of each exercise.
 * @http://ckm.osu.edu/sitetool/sites/sportsmedicinepublic/documents/Rehabilitation_Protocols_2010/Throwers_Ten_Exercises_2010.pdf

> < http://www.nwtsportsmed.com/discus/messages/25/146.html?TuesdayOctober3120060748pm>.
 * References**
 * Author unknown. (2009). Rotator Cuff Repair Rehabilitation Program. Gundersen Lutheran Sports Medicine. <@http://www.gundluth.org/upload/docs/Services/SportsMedicine/shld-RTCrepair-small-medium-comprehensive-2009-3-23-09.pdf>
 * DeBerry, Tommy. (2002). The Rotator Cuff: Mechanism of Injury, Testing, and Rehab. //Northwest Texas Sports Medicine Clinic.//
 * Escamilla, R., Yamashiro, K., Paulos, L., Andrews, J., (2009). Shoulder muscle activity and function in common shoulder rehabilitation exercises. //Sports Medicine//, 39(8), 663-685.
 * Ghodadra, N., Provecher, M., Verma, N., Wilk, K., & Romeo, A. (2009). Open, mini-open, and all-arthroscopic rotator cuff repair surgery: Indications and implications for rehabilitation. //Journal of orthopaedic and sport physical therapy// //, 39// (2), 81-89.
 * Maloney, M., & Ryder, S. (2003). Diagnosis and management of rotator cuff tears: symptoms usually can be resolved with appropriate conservative treatment. //The Journal of Musculoskeletal Medicine//, //20//(2), 87.
 *  Moosmayer, S., Tariq, R., Stiris, M., & Smith, H. (2010). MRI of symptomatic and asymptomatic full-thickness rotator cuff tears: A comparison of findings in 100 subjects. // Acta Orthopaedica //, // 81 // (3), 361-366.
 *  Pegreffi, F., Paladini, P., Campi, F., & Porcellini, G. (2011). Conservative management of rotator cuff tear. // Sports Medicine and Arthroscopy Review // , // 19 // (4), 348-353.
 * Reinold, M., Escamilla, R., Wilk K., (2009). Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature //, J Orthop Sports Phys Ther//; 39(2):105-117.
 * Reinold M., Macrina L., Wilk K., Dugas J., Cain EL, Andrews JR. (2008). The effect of neuromuscular electrical stimulation of the infraspinatus on shoulder external rotation force production after rotator cuff repair surgery.//Am J Sports Med//. 36(12): 2317-21.
 *  Reinold, M., Wilk, K., Reed, J., Crenshaw, K., & Andrews, J. (2002). Interval sports programs: Guidelines for baseball, tennis, and golf. //Journal of orthopaedics and sports physical therapy, 32//(6), 293-298.