Phase4 (12~16weeks)

Goal

Exercise

complete tendon healing mature repaired rotator cuff tissue

 

advanced strengthening

 

maximum tensile endurance

 

 

1. OKC strengthening

* standing ER - infraspinatus & teres minor

- standing AB90,ER - supraspinatus(at least after 16wks)

- scaption(at least after 16wks), (at least after 24wks: large & massive tear)

- Emphasize eccentric exercise

 

2. scapulo-thoracic exe

* standing punch plus( SA activation):90~120° (after 16wks)

- puch-up plus (wall ->table ->floor)

 

3. proprioception

* rhythmic stabilization exe- F90°("statue of liberty position"), ABER position

4. plyometric exe

overhead motion : throw against a wall, rebounder, weighted ball

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 26weeks of healing

Plyometric exe: only large & massive tear(at least 24weeks)

Postperative months 3~6

* No heavy overhead lifting and no acceleration of arm in sport.

* For massive tears and revision repairs, delay strengthening until 4 months postoperatively

 

Remodeling repair tissue does not reach maximal tensile strenght for a minimum of 12~16 weeks post repair.

 

 

 

Progressive post cuff strengthening

Progressive strengthening of the posterior cuff

* performing external rotation of the shoulder at 30~45° degrees of abduction utilizing elastic resistance

high levels of infraspinatus and teres minor activation at 90° of abduction

* performing external rotation exercise, supraspinatus muscle activity is optimally generated

 

abduction

* performing external rotation exercise, supraspinatus muscle activity is optimally generated

 

 

Progressive OKC exe

Progressive CKC

Additionally, the push-up with a plus progresstion is a more advanced exercise that strengthens the serratus anterior muscle

Reference

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

 

Musculoskeletal evidence based treatment

 

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 208245Google 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

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

 

Phase3 (8~12weeks)

Goal

Exercise

Minimal tensile strength in cuff repair (complete tendon to bone healing)

 

PROM, AROM

 

Periscapular OKC exe

 

CKC stability exe

 

1. isometric strength exe

2. dynamic hug(SA activeation)

* elbow FL45° ,shoulder AB 60°, IR45°

3. Band standing & prone row: Trapezius & Rhomboid(scapular stabilizer)

4. Biceps & triceps

* elastic band or without resistance

5. CKC(60~90°): weight shift- one hand support

*CKC stability exe : improved neuromuscular control & static stability

Remodeling repair tissue does not reach maximal tensile strength for a minimum of 12~16 weeks post repair

* Dynamic activity(after 10wks)

* AROM activity

* Avoid ER/IR band exe(only large & massive tear: at least 16wks)

 

Isotonic periscapular & CKC exercise

Phase1 (1~4weeks)

Goal

Exercise

inflammatory, proliferative & repair phase.

Protected tendon healing

PROM

Scapular realignment

 

1. Passive Rom

2. short-arm traction(IR/ER)

3. assisted forward flextion

4. scapular depression & protraction

(minimal posterior RC acivity)

5. pendulum(infra/supra MVIC 15%)

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 208245Google 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

30abduction 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 208245Google 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

Active

Compression of joint surfaces

Dynamic ligament tension

N-M control

정적요소

Passive

Joint geometry

Adhesion/cohesion

Ligamentous restraints

Soft tissue barrier

Glenoid labrum

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 208245Google 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

 

회전근개 수술을 하신분들이 많습니다. 

회전근개 수술후 재활을 위한 글을 아래와 같은 차례로 포스팅하겠습니다.

 

Glenohumeral Joint problem.(rotator cuff 편)

 

목차

Glenohumeral Joint 의 정의

 

Rotator cuff 소개

 

Rotator cuff 중요성

 

Rotator cuff repair

 

Rotator cuff repair reheb protocol

 

 

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