몸 마음 영혼을 건강하게

Phase4 (12~16weeks)

⇒ 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 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

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

Phase2 (4~8weeks)

⇒ PSOT OP 0~6weeks

* Limited to 45° for small to large posterior-superior suff tears

-Limited to 0° (straight ahead)for massive tears and subscapularis tears(No AA,AROM)

-Full AROM(only small & medium tear)

Phase2 (4~8weeks)

▣ Gradually restore muscle strengh and proprioception thereby establishing muscular balance

▣ PSOT OP 0~6weeks

-Limited to 45° for small to large posterior-superior

cuff tears

-Limited to 0° (straight ahead)for massive tears and subscapularis tears(No AA,AROM)

-No active assisted motion

▣ Active Range of Motion (6~12 weeks)

□ Use of AAROM during this timeframe

- including supine glenohumeral external and internal rotation with a cane as well as supine flextion with the assistance of the uninvoved limb

□ scapular plane

- shown to have less rotator cuff EMG activity, in terms of percent of maximal voluntary isometric contraction

- first 30~60° scapular plane elevation: superior translation

- 30~60° lying supine abduction: inferior translation

The salute exercise

- is an effective way to initiate recruitment of the supraspinatus muscle fibers

- This exercise can be progressed to "the full can acvivity", which is known th exhibit high supraspinatus muscle activity

AAROM ex

Deltoid reeducation

□ This deltoid muscle rehabilitation regimen, associated with pain medication, was effective in improving the function and pain in elderly patients with massive cuff tears, reverse total shoulder arthroplasty

Isometric & muscle recruitment

Back & periscapular exe

Started CKC exercise

□ started closed chain stability exercises

* improve neuromuscular control of the shoulder complex

□ Rhythmic stabilization(supine, quadruped)

* increase muscle activation and improve static stability of the shoulder complex

□ The exercise may be started at elevations of 60° or less and then moved up to 90° as tissue healing allows.

□ 3 weeks after surgery for glenoid labral repair or instability repair

□ 5 weeks after rotator cuff repairs

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

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

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