몸 마음 영혼을 건강하게

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