몸 마음 영혼을 건강하게

Phase1 (1~4weeks)

⇒ Avoided end range stretch (first 6 weeks), active exe

● Avoided pulley exe

● Avoided elevation from 30 to 60° (more 2 tendon injury, subscapularis injury)

Phase1 (1~4weeks)

▣ collagen deposition and growth factors increase, with a peak increase around 10 days after surgery

▣ repair should not be exposed to the excessive forces inposed by active motion

▣ Pressure at the end range (stretching) should be avoided for the first 6 weeks

▣ PROM is progressed with caution

□ Started periscapular activation

- isolated scapular depression, retraction performed and has shown to exhibit minimal posterior RC cuff activity

□ Approximately 20~30° of scapular plane

- preventing decreased blood flow in the supraspinatus

- increasing the subacromial space

PROM & Scpaular setting

reference

Myers, Joseph B. shoulder muscle reflex latencies under various levels of muscle contraction. Clinical Orthopaedics & Related Research. 407:92-101, February 2003.

Frederick A. Matsen, III, Caroline Chebli and Steven Lippitt. Principles for the Evaluation and Management of Shoulder Instability. J Bone Joint Surg Am. 2006;88:647-659.

Morrey BF, An KN (1990) Biomechanics of the shoulder. In: Rockwood CR, Matsen FA (ed) The shoulder. Saunders, Philadelphia, pp 208–245Google Scholar.

Philip Mcclure, Lori A. Michener. Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. Published in Journal of shoulder and elbow surgery 2001

Parsons IM1, Apreleva M, Fu FH, Woo SL. The effect of rotator cuff tears on reaction forces at the glenohumeral joint. J Orthop Res. 2002 May;20(3):439-46.

MET

Young Jin Jo1, Young Kyun Kim. Consideration of Shoulder Injury Prevention and Rehabilitation Exercise for Overhead Sports Population. Asian J Kinesiol 2019; 21(2): 40-50 · DOI: https://doi.org/10.15758/ajk.2019.21.2.40

Ofer Levy, Hannan Mullett, The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears. Medicine Published in Journal of shoulder and elbow surgery2005 DOI:10.1016/j.jse.2008.04.005

https://www.hep2go.com/index_b.php?userRef=120148

Olivier A. van der Meijden, MD1. Rehabilitation after arthroscopic rotator cuff repair: Current concepts review and evidence-based guidelines. International Journal of Sports Physical Therapy · April 2012

회전근개에 문제가 생겨 재봉합하는 수술

재활의 목적 > 통증완화와 가동범위 회복, 기능 회복

합병증 보통 1.5% ~ 2.7%로 환자들의 어깨 움직임시 뻣뻣함 호소 > 치료시 신경써야한다.

재활가이드라인

회복 초기는 조직의 회복과 염증 통증감소 수술부위의 보호가 가장 중요.

수술 직후 4~6 주까지는 팔을 고정해주는 것이 중요하며 수술 후 어깨의 뻣뻣함 줄이기 위해 적절한 ROM운동이 필요하다.

회복과정은 3가지 단계로 구분

1 염증기 2 회복기 3재형성기

Operative treatment

Retear time rate

□ 22 patients with large or massive tears (>3cm)

- immobilization 4 week, strengthening 12 weeks

□ 66% retears, occurred within 3 months

□ 33% tetears, occurred after 6 months

□ No retears from 6 to 24 months

ROM gains

□ Type 1 : small tears (1cm, very good tissue quality)

- Full AROM 6~8 weeks

□ Type 2 : large tears ( <3~5cm, adequate tissue)

- Full AROM 8~12 weeks

□ Type 3 : large massive tears ( 3~5cm<, poor tissue, retracted tissue)

- Full AROM 12~16 weeks

Rotator cuff tensile strength

□ Ablilty to tolerate up to 100 N/mm of tensile strength

□ However, the tendons' endurance of compressive and shear forces is much less

□ Irritation and inflammation of the subacromial bursa which is rich in nerve fibers

Bursa

□ protection from shearing forces

□ contribute to the blood supply

□ healing of the rotator cuff particularly

□ preservation of the tissue

□ Bursectomy

- lead to rotator cuff tears or adhesions of the tendons of capsule

Tendon Healing Potential

□ Partial -thickness, small full thickness tears of the rotator cuff may heal spontaneously.

□ Most small tears will enlarge if not surgically repaired

Rotator cuff healing stage

염증기 > 증식기 > 재형성기

염증기

* Following surgical tendon-to-bone fixation

* Occurs first 7 days

* The release of histamine and bradykinin increases vascular permeability

* Inflammatory cells followed by platelets and fibroblasts migrate into the repair site

* Cellular proliferation and matrix deposition of this phase is thought to be regulated by several growth factors and initially yields primarily type 3 collagen.

증식기

* When next 2~3 weeks, begin to proliferate or repair

* This tissue replaces, which occurs 2 to 3 weeks after tendon ingury or repair

* Combine with capillary buds and nascent extracellular matrix to form granulation tissue.

재형성기

* During the following week(after 4weeks), this repair tissue grows stronger during the transition to the maturation phase.

* Scar tissue organizes through extracellular matrix turnover.

* The initial type 3 collagen deposition is slowly replaced by type 1

collagen, continuing until mature scar tissue is formed

* Remodeling repair tissue does not reach maximal tensile strength for a minimum of 12~16 weeks post repair, returned to maximal failure loads after only 26 weeks of healing.

Fisk factors of stiff shoulder after cuff repair

□ Calcific tendinitis

□ Adhesive capsulitis

□ PASTA type repair

□ Concomitant SLAP repair

□ Single tendon repair

Effect of immobilization

□ Postoperative immobilization can minimize the tension on rotator cuff repairs and may lead to improved collagen orientation and visco-elastic properties as compared to immediate postoperative exercise treatment

□ Immobilization of the shoulder for 4-6 weeks in a slightly abducted position may minimize tension and maximize vascularization of the repair

신장분사 치료

□ post-surgically to decrease pain, swelling, muscle spasm, and minimize the inflammatory response

□ authors recommend the use of a home cryotherapy device for 10-14 days after surgery

관절 가동술

□ 30도 abduction in the scapular plane

- anterior and posterior translational glides do not significantly alter stress on repaired supraspinatus tendons with the arm in resting position.

□ Especially, posterior translational glides have shown to significantly increase external rotation range of motion in patients with stiff shoulders.

□ Progressed ROM to 4-6 weeks after surgery

exercise

Joint play (posterior gliding)

Gird streching

Latissimus dorsi streching

Shoulder ER/IR

Shoulder retraction

Shoulder protraction

Scaption

eccentric contraction

reference

Myers, Joseph B. shoulder muscle reflex latencies under various levels of muscle contraction. Clinical Orthopaedics & Related Research. 407:92-101, February 2003.

Frederick A. Matsen, III, Caroline Chebli and Steven Lippitt. Principles for the Evaluation and Management of Shoulder Instability. J Bone Joint Surg Am. 2006;88:647-659.

Morrey BF, An KN (1990) Biomechanics of the shoulder. In: Rockwood CR, Matsen FA (ed) The shoulder. Saunders, Philadelphia, pp 208–245Google Scholar.

Philip Mcclure, Lori A. Michener. Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. Published in Journal of shoulder and elbow surgery 2001

Parsons IM1, Apreleva M, Fu FH, Woo SL. The effect of rotator cuff tears on reaction forces at the glenohumeral joint. J Orthop Res. 2002 May;20(3):439-46.

MET

Young Jin Jo1, Young Kyun Kim. Consideration of Shoulder Injury Prevention and Rehabilitation Exercise for Overhead Sports Population. Asian J Kinesiol 2019; 21(2): 40-50 · DOI: https://doi.org/10.15758/ajk.2019.21.2.40

Ofer Levy, Hannan Mullett, The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears. Medicine Published in Journal of shoulder and elbow surgery2005 DOI:10.1016/j.jse.2008.04.005

https://www.hep2go.com/index_b.php?userRef=120148

Olivier A. van der Meijden, MD1. Rehabilitation after arthroscopic rotator cuff repair: Current concepts review and evidence-based guidelines. International Journal of Sports Physical Therapy · April 2012

GH joint stability

동적요소

정적요소

only 25~30% of the humeral head is in contact with the glenoid fossa.

Dynamic factors

●Rotator cuff

▷increase joint stability

▷increase joint compression

▷steering

Function of rotator cuff

Relationship of supraspinatus & deltoid muscle

Force coupling compression force

● Controlling shoulder motion and stability

● Reduce anterior translation

Biceps long head

● Attach on the anterior, superior glenoid

● Contraction of biceps

▷ Decrease in superior & anterior translation

※ GIRD

GH joint biomechanics

First 30~60° scapular plane elevation: 1-3mm superior translation

30~60° lying supine abduction: 0.7mm inferior translation

not similarly recruit muscle activity

During passive glenohumeral motion, limited evidence demonstrates that during 30~60° superior translation occurs

GH joint 운동형상학(kinematics)

First 30~60° at scapular plane

0.7~2.7mm anterior translation

60~90°

0~1.5mm posterior translation

90~120°

1~4.5mm posterior translation

▶ Exernal rotation is important for clearance of the greater tuberosity during elevation

Effect of external rotation during elevation

▷increase humeral external rotation at scapular plane than sagittal and coronal plane.

▷Exernal rotation

its associated tissues as it passes under the coracoacromial arch

Effect of humeral ER

GH Joint Kinematics

● Subscapularis teres minor, infraspinatus contribute to depression of the humeral in the glenoid cavity more than does the supraspinatus. And/or provides dynamic stability to the GH joint during deltoid activation.

Subacromial space

● Height of the subaromial space

▷ 1~1.5cm

● At 90 elevation(healthy)

▷ 4.1mm

● Shoulder impingement

▷ 1.4mm

⇒ 6mm Superior displacement of humeral head if rotator cuff tear space effect

출처

Myers, Joseph B. shoulder muscle reflex latencies under various levels of muscle contraction. Clinical Orthopaedics & Related Research. 407:92-101, February 2003.

Frederick A. Matsen, III, Caroline Chebli and Steven Lippitt. Principles for the Evaluation and Management of Shoulder Instability. J Bone Joint Surg Am. 2006;88:647-659.

Morrey BF, An KN (1990) Biomechanics of the shoulder. In: Rockwood CR, Matsen FA (ed) The shoulder. Saunders, Philadelphia, pp 208–245Google Scholar.

Philip Mcclure, Lori A. Michener. Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. Published in Journal of shoulder and elbow surgery 2001

Parsons IM1, Apreleva M, Fu FH, Woo SL. The effect of rotator cuff tears on reaction forces at the glenohumeral joint. J Orthop Res. 2002 May;20(3):439-46.

Young Jin Jo1, Young Kyun Kim. Consideration of Shoulder Injury Prevention and Rehabilitation Exercise for Overhead Sports Population. Asian J Kinesiol 2019; 21(2): 40-50 · DOI: https://doi.org/10.15758/ajk.2019.21.2.40

Ofer Levy, Hannan Mullett, The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears. Medicine Published in Journal of shoulder and elbow surgery2005 DOI:10.1016/j.jse.2008.04.005

https://www.hep2go.com/index_b.php?userRef=120148

회전근은 어깨뼈에서 시작하여 위팔뼈 위쪽 부분에 붙는 가시위근, 가시아래근, 어깨밑근, 작은원근을 말한다. 가시위근은 팔을 벌리는 기능을 하고 가시아래근과 작은원근은 팔을 바깥으로 돌리는기능을 하며 어깨 밑근은 팔을 안쪽으로 돌리는 기능을 한다. 회전근은 팔을 움직이는 역할을 할 뿐 아니라 관절오목에 대하여 위팔뼈 머리의 안정성을 제공한다.

어깨관절은 그 자체만으로는 불안정하기 때문에 회전근은 어깨 관절의 안정성을 유지하는 데 매우 중요한 역할을 한다.

▷가시위근 : 어깨뼈의 가시위오목에서 시작하여 위팔뼈 큰결절의 윗 면에 붙는다. 어깨위신경의 지배를 받는다.

▷가시아래근 : 어깨뼈의 가시아래오목에서 시작하여 위팔뼈 큰결절의 중간면에 닿는다. 어깨위신경의 지배를 받는다.

▷작은원근 : 어깨뼈 가쪽모서리 중간에서 시작하여 위팔뼈 큰결절 아랫면에 닿는다. 겨드랑 신경의 지배를 받는다.

▷어깨밑근 : 어깨뼈의 밑오목에서 시작하여 위팔뼈 작은결절에 붙는다. 어깨밑신경의 지배를 받는다.

출처

서울대학교병원 신체기관정보.

Glenohumeral Joint 의 정의

Glenohumeral Joint

GH joint는 위팔뼈머리의 큰 볼록면과 관절오목의 얄은 오목면 사이에 형성된 관절이다. 이 관절 은 어깨의 큰 가동범위를 만들어내기 위해 어깨뼈의 움직임과 연합 하여 작용한다.

해부학적 위치에서 관절오목의 관절면은 어깨면쪽 방향인 앞 가쪽으로 향해 있다. 대부분의 사람에 있어， 관절오목은 약간 위쪽으로 돌림되어 있다.

해부학적 위치에서， 위팔뼈머리는 안쪽과 위쪽으로 향하고 있으며， 뒤굽음(retroversion)의 특성에 의해 뒤쪽으로도향하고 있다. 이러한 방향에 의해 위팔뼈머리는 어깨면에 놓이게 되어， 관절오목 의 관절면과 바로 마주보게 된다.

GH joint는 3도의 자유도 모두에서 움직임이 일어나기 때문에 만능관절 이다. GH joint에서의 일차적 운동은 굽힘과 폄 벌림과 모음, 그리고 안쪽 돌림과 가쪽돌림이다.

출처

서울대학교병원 신체기관정보.

뉴만