Abstract

This Chapter reviews the factors, biologic healing, early and delayed range of motion, and guidelines of rotator cuff post-operative physical therapy and rehabilitation. The guidelines discuss in detail the four phases of rehabilitation including maximal protection, muscular endurance, muscular strength and muscular power.

Keywords: Rotator Cuff, Rotator Cuff Physical Therapy, Rotator Cuff Rehabilitation

Introduction

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  Rotator cuff tears (RCTs) are one of the most prevalent shoulder pathologies, occurring in 13% of people older than 50 years and more than 50% of people 80 years and older ( ).

  
  
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  Massive tears make up 20% of all RCTs and 80% of all reoccurring tears ( ).

  
  
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  Although RCTs can be asymptomatic, many people experience pain, muscle weakness, and loss of range of motion (ROM), resulting in altered glenohumeral kinematics.

  
  
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  Current research supports initial conservative physical therapy management for full-thickness RCTs ( ).

  
  
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  In the past 10 years, the rate of arthroscopic rotator cuff repair (RCR) has increased by 600% ( ).

  
  
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  The objective of postoperative rehabilitation is to restore overall function without compromising the integrity of the repaired tissue.

Factors Affecting Postoperative Outcomes

The mechanism of injury (acute vs. chronic, traumatic vs. overuse), type of surgery performed, and subsequent physical therapy following a repair are just a few factors that can affect the surgical outcome. There are several factors, preoperative and postoperative, that play a role in and affect the outcome of rehabilitation following a RCR ( ). Table 10A.1 provides an outline of several important intrinsic and extrinsic prognostic factors that can be used to determine an expected level of success with rehabilitation; these factors are also associated with a higher rate of recurrent RCT ( ).

Poor compliance with postoperative rehabilitation is a significant independent prognostic factor that can result in poor functional outcomes or recurring RCTs ( ). Therefore patient education regarding the postoperative precautions, restrictions, and rehabilitative program is imperative for a successful outcome ( ). Older age, typically more than 60 years, is associated with less optimal functional outcomes and longer healing and recovery times ( ). A systematic review performed by identified 12 significant prognostic factors that affect rehabilitation and long-term outcomes following RCR. The positive predictive prognostic factors that affect healing and subsequent rehabilitation and recovery after an RCR were found to be: age less than 60 years, male gender, high bone mineral density (BMD), absence of diabetes mellitus (DM), high level of preoperative activity, good preoperative shoulder ROM, absence of obesity, smaller sagittal tear size, less tendon retraction, low amount of fatty infiltration, single tendon involvement, and no other procedures being performed concurrently with the RCR ( ). Acute RCTs typically manifest with less fatty infiltration and less tendon retraction, so rehabilitation expectations are more favorable than for chronic progressive tears. Large RCTs are associated with greater tendon retraction, greater fatty infiltration, and increased muscle atrophy and have a higher failure rate than small RCTs ( ). It is important to consider both intrinsic and extrinsic prognostic factors for each patient in order to determine an accurate prognosis and to set appropriate expectations for the patient regarding duration of rehabilitation and return to functional and athletic activities. Table 10A.1 can be utilized as a guide to determine whether a moderate, intermediate, or conservative rehabilitation approach is most appropriate for a particular patient.

Subjective quantification of patient satisfaction should be measured at baseline and periodically throughout rehabilitation with the use of functional outcome measure forms specific to the shoulder. Outcome measures commonly used to assess subjective function and quality of life include the American Shoulder and Elbow Surgeons (ASES) score, the Disability of the Arm, Shoulder and Hand (DASH) score, the Western Ontario Rotator Cuff Index (WORC), the Constant-Murley score, the Single Assessment Numeric Evaluation (SANE), and the Medical Outcomes Study Instruments Short Form 12 (SF-12) and Short Form 36 (SF-36) ( ).

Force Couples of the Rotator Cuff and Scapulothoracic Musculature

The rotator cuff is composed of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, which together with the glenohumeral joint capsule and ligaments provide a unique balance of dynamic control and stability to the glenohumeral joint, which inherently lacks bony stability. The rotator cuff musculature in concert with the scapulothoracic musculature generates force couples that enhance dynamic stability and promote normal scapulohumeral rhythm. Normal scapulohumeral rhythm has been defined by Inman et al as 2 degrees of glenohumeral motion for every 1 degree of scapular motion, which generally results in 120 degrees of glenohumeral motion in addition to 60 degrees of scapular rotation in order to achieve 180 degrees of shoulder elevation ( ). The force couples provided by co-contraction of the rotator cuff musculature are important for approximation of the humeral head in the glenoid as well as to generate the appropriate amount of torque required for rotation of the joint, both of which are crucial to establish proper kinematics of the upper extremity with functional activities.

The anteroposterior force couple of the rotator cuff, which is established by opposing forces of the subscapularis and infraspinatus/teres minor muscles, is essential to creating the dynamic compression mechanism required to provide stability to the glenohumeral joint. This force couple, along with co-contraction of the supraspinatus, also counteracts the superior force generated by the deltoid with shoulder elevation and produces a dynamic caudal glide of the humeral head in the glenoid to allow for proper translation of the humerus, crucial for activities above shoulder level. The integrity of each force couple directly affects the kinematics of the glenohumeral joint; when a force couple is disrupted as a result of injury or weakness, the magnitude and direction of the force couple are also affected ( ). The result is decreased compression of the humeral head in the glenoid, and therefore decreased dynamic stability, leading to altered glenohumeral kinematics.

Proper kinematics of the scapulothoracic joint are essential to establish normal scapulohumeral rhythm. Function of the glenohumeral joint is affected when the force couple between the serratus anterior and middle/lower trapezius muscles is compromised by strength deficits or muscle dysfunction secondary to chronic compensation patterns. Decreased muscle activation of the rotational force couple created by the serratus anterior and middle/lower trapezius results in decreased stability and altered kinematics of the scapula during glenohumeral motion, causing inefficient mechanics of the shoulder complex as a whole, which in turn produces increased stress on the structures within and surrounding the glenohumeral joint ( ).

Tissue Healing Timelines

Soft tissue and tendon healing consists of three main phases: inflammation, proliferation, and maturation. The inflammatory phase begins at the time of injury and lasts up to 5 days after trauma or surgical repair. In this phase, inflammatory cells remove tissue debris and form callus consisting of type I and III collagen fibers ( ). Proliferation begins after the inflammatory phase and can last up to 6 weeks; this phase is characterized by fibroblastic repair and sets the stage for deposits of collagen and extracellular matrix ( ). During this repair phase, overly vigorous mechanical loading can reignite the inflammatory phase and result in weaker tissue. The maturation phase begins at weeks 6 to 8 after surgical repair and can last more than a year. In this phase, collagen fibers respond to gradually progressive stress and strain to realign in a position of maximum efficiency parallel to the lines of tension ( ). Larger rotator cuff tears have been shown to exhibit less fibroblastic activity and therefore more limited proliferation in comparison with smaller rotator cuff tears, a difference that slows the physiologic rate of tissue healing ( ).

Early Versus Delayed Range of Motion

There are many studies comparing early versus delayed ROM following an RCR. Some surgeons choose immobilization for a period ranging from 2 to 6 weeks postoperatively in order to protect the repaired tissue from overloading and from increased tension on the repair that may negatively affect the healing potential, whereas other surgeons select early passive mobilization in order to reduce risk of postoperative shoulder stiffness and to improve early function without overloading the surgical repair. A 2015 meta-analysis showed that an ROM protocol begun early postoperatively reduced postoperative stiffness; however, it found no difference between early and delayed ROM protocols regarding overall shoulder function ( ). Early ROM protocols are most beneficial when utilized for the patient with a small to medium RCR and no intrinsic risks of improper healing as well as for those with preoperative presentation of restricted ROM ( ). Delayed ROM protocols are favored for large to massive cuff tears as determined by tissue and repair integrity in order to ensure appropriate healing ( ). Tendon healing responds well to controlled loading; overloading may result in an ineffective repair but underloading may not stimulate the repair site enough for proper healing ( ). A proper rehabilitation protocol should be constructed according to an analysis of the risks and benefits, that is, considering both protection of tissue integrity and prevention of postoperative stiffness ( ). Good communication between the physical therapist and surgeon is paramount to establish a proper rehabilitation program that achieves optimal results for each patient.

Guidelines for Rotator Cuff Repair Rehabilitation

As with all postoperative rehabilitation programs, it is important to consider physician recommendations in conjunction with prognostic factors (see Table 10A.1 ) as well as criterion-based and healing timeline–based progression to advance through the phases of rehabilitation. The phases of rehabilitation, as described here, and the algorithm shown in Fig. 10A.1 were developed with regard to healing timelines and criterion-based and function-based progression.

Shoulder progression criteria algorithm. ABD, abduction; ADLs, activities of daily living; AROM, active range of motion; CKCUEST, closed kinetic chain upper extremity stability test; DASH, Disability of the Arm, Shoulder and Hand (score); ER, external rotation; FE, forward elevation; GH, glenohumeral; HHD, hand held Dynamometer; IR, internal rotation; med, medicine; MMT, manual muscle test; plyo, plyometric; ROM, range of motion; UE, upper extremity.

Phase I: Maximal Protection

The primary goals during the maximal protection phase are to protect the integrity of the repaired tissue, minimize pain and inflammation, and improve passive ROM without compromising the surgical repair. Postoperatively, the arm is placed in a sling with an abduction pillow, allowing the glenohumeral joint to assume an open-packed position in the scapular plane. On the basis of multiple factors, including the structural integrity of the RCR as determined by the orthopedic surgeon, ROM may begin early or is delayed.

During the initial rehabilitation visit, the physical therapist reviews postoperative restrictions and educates the patient regarding phase I goals, precautions, a home exercise program, and wound management. It is important to review restrictions on passive and active ROM as well as to provide education regarding tendon/tissue healing. When passive ROM is allowed by the surgeon, it should be performed in a manner as to not stress the repair yet still allow for protected maintenance of mobility and joint nutrition. Passive ROM performed in the supine position has been shown to produce a very low electromyographic (EMG) activity of the rotator cuff musculature and therefore is safe in this stage of rehabilitation (McCann et al, 1992). ROM restrictions can vary according to factors such as tissue quality, comorbidities, and quality of the repair.

Patient education should be provided about home exercise, programs including active ROM of the cervical spine, hand, wrist, and elbow performed without the sling, and hand pumping or ball-squeeze exercises in order to reduce edema and facilitate circulation in the distal upper extremity. Scapular retraction, protraction, elevation, and depression exercises are also indicated during this phase to facilitate early neuromuscular activation and control of the scapula. The use of cryotherapy and compression is recommended throughout this phase as needed to reduce pain, decrease inflammation, and improve comfort for sleeping ( ). Physical or occupational therapists provide instruction on performing activities of daily living, such as sleeping, using the sling, showering, and dressing.

The criteria to progress to the next phase of rehabilitation, muscular endurance, are shown in Fig. 10A.1 . Advancement of a patient to the next phase of a rehabilitation program requires not only that the patient meet the criterion necessary to progress but also consideration of physician and tissue healing guidelines.

Phase II: Muscular Endurance

The second phase of rehabilitation begins when the patient (1) is cleared by the surgeon to do so—typically 4 to 8 weeks postoperatively and determined by the integrity of the repaired tissue—and (2) has met the criteria for progression from phase I. The goals of this phase focus on restoring active ROM with emphasis on proper muscle activation in conjunction with muscular endurance.

Progression from passive to active assisted ROM prior to the initiation of active ROM is the preferred sequence so as to gradually increase the amount of load on the repair. Full passive ROM in all planes is not expected at this point postoperatively and most likely will have to be incorporated into treatment sessions as indicated. Active assisted and active ROM exercises in open kinetic chain positions should focus on the movement taking place as well as on proper muscle activation to avoid the development of compensation patterns.

Generally, the patient begins active assisted ROM exercises in a supine position to reduce the demand of muscle activation placed on the rotator cuff musculature and progresses to a seated or standing position. Active assisted ROM exercises should focus on planes of motion, including forward elevation, abduction, and internal and external rotation.

Submaximal isometric exercises are initiated in this phase, focusing on the deltoid, infraspinatus, subscapularis, triceps, and biceps as appropriate. Such exercises promote muscle activation in a controlled position so as to prevent atrophy, increase strength, and decrease pain; they act as a mechanical pump to decrease joint effusion. Pendulums, also known as Codman’s exercise, can also be initiated in this phase because EMG activity research has shown that small pendulums, performed correctly, do elicit rotator cuff activation; pendulums performed incorrectly generate increased supraspinatus activity ( ).

Aquatic therapy can also be initiated in this phase in order to provide gentle assist with movement; it has been documented that forward elevation performed in the water at slower speeds results in lower activation of the rotator cuff musculature than the same movement on land, allowing for active assisted ROM with less demand on the repair ( ). Open chain proprioception exercise is also commenced at this time, first with patient supine performing small, controlled movements and then submaximal manual perturbations in various patterns. Such exercise should initially be performed at glenohumeral forward elevation to 90 degrees as well as in neutral glenohumeral rotation; various angles and positions can be utilized for progressions. It is important for the physical therapist to monitor scapular position and control with submaximal isometric, open chain proprioception, and active assisted and active ROM therapeutic exercises.

Active ROM is typically initiated once the patient is able to perform active assisted ROM exercises with minimal to no pain throughout the motion and/or at end ranges. Active ROM exercises should focus on reestablishing proper muscle activation of the rotator cuff in a slow, purposeful manner.

Active ROM exercise is typically initiated with the patient in a supine position, progressing to seated or standing positions as neuromuscular control and endurance improve over time. The following exercises have been documented in the literature as some of the best exercises because EMG activity research shows that they emphasize the rotator cuff muscles without overactivation of larger muscle groups such as the pectoralis major, latissimus dorsi, and deltoid.

Regarding activation of the infraspinatus, sidelying external rotation with an underarm towel roll and prone external rotation abduction exercises have been shown to provide the highest EMG activity ( ). Initially, exercises performed prone with external rotation at 90 degrees of abduction place too much tensile load on the repaired musculature, so sidelying external rotation is the preferred exercise for initial active external rotation. The addition of a small towel under the arm places the glenohumeral joint in the scapular plane, allowing for low capsular strain, decreased compensatory patterns, and greater EMG activity of the external rotators ( ). In addition, this position optimally positions the glenohumeral joint for strengthening of the external rotators, promotes scapular stabilization, and creates an adduction force on the glenohumeral joint, resulting in an larger subacromial space and allowing for less stress on the tissues within this space ( ).

Initial activation of the supraspinatus can be achieved with a supine or seated “salute” exercise performed with a flexed elbow to shorten the lever arm and reduce tensile load on the muscle. This exercise incorporates scapular plane elevation with static external rotation and can be progressed to an upright position full can exercise. The full can exercise has been shown to produce optimal activation of the supraspinatus muscle as well as to demonstrate significantly less concurrent deltoid activation ( ).

The primary function of the subscapularis is as an internal rotator of the glenohumeral joint. Initial subscapularis activation is achieved with isometric exercises and eccentric control during external rotation activation. The subscapularis has also been shown to have higher EMG activity with prone external rotation and horizontal abduction exercises ( ).

Retraining the deltoid for functional activities begins with a supine press to 90 degrees of glenohumeral forward elevation, progressing to an incline press and finally an upright seated press. The prone full can exercise has been shown to generate good EMG activity of the posterior deltoid fibers as well as lower trapezius and is effective for scapular stabilization ( ).

The serratus anterior protracts the scapula and is essential to normal scapulohumeral kinematics. It is initially activated utilizing the “plus” exercise in a supine position with the glenohumeral joint in a static forward elevated position. Emphasis is placed on protraction and retraction of the scapula, first performed at 90 degrees of glenohumeral forward elevation and then progressing to 120 degrees of forward elevation.

Scapular stability is a crucial component of rotator cuff rehabilitation and should be progressed along with glenohumeral active ROM in order to establish normal scapulohumeral rhythm. Building off scapular retraction and depression, which were initiated in phase I of rehabilitation, it is important to promote proper muscle activation of the scapulothoracic musculature while concurrently reducing compensatory activation of the upper trapezius. Emphasis on neuromuscular activation and endurance of the middle and lower trapezius, rhomboids, and serratus anterior is key to establishing normal scapulohumeral rhythm with active ROM prior to initiating resisted ROM. Sidelying external rotation, sidelying forward flexion, prone horizontal abduction with external rotation, and prone extension exercises have been shown to demonstrate high levels of middle trapezius, lower trapezius, and rhomboid activity with minimal upper trapezius activation ( ).

Capsular and soft tissue restrictions of both the glenohumeral and scapulothoracic joints as well as accessory joints should be considered and can be addressed with a variety of manual techniques, including but not limited to soft tissue mobilization, joint mobilization, contract/relax techniques, and low-load, long-duration stretching, with the repaired tissues and healing timelines kept in mind. It is important to identify which soft tissues are restricted and to prescribe appropriate stretching exercises on the basis of objective findings. Common stretches to incorporate at this time focus on the posterior shoulder, latissimus dorsi, and the anterior shoulder musculature, specifically the pectoralis major and minor, and should be utilized to improve ROM. The therapist should ensure that proper mobility is attained throughout the cervical and thoracic spine, and scapulothoracic, glenohumeral, acromioclavicular, and sternoclavicular joints, because restriction in one of these joints may affect overall mobility and function of the entire upper extremity.

The criteria for progression to the muscular strength phase are outlined in Fig. 10A.1 . The required ROM to complete all activities of daily living without restriction is 120 degrees of forward elevation, 45 degrees of extension, 130 degrees of abduction, 115 degrees of horizontal adduction, 60 degrees of external rotation, and 100 degrees of internal rotation ( ). At this point, the patient is expected to achieve the necessary active ROM required to perform specific functional tasks, exhibit normal scapulohumeral rhythm with active ROM greater than 90 degrees, and to pass the fatigue protocol test.

Phase III: Muscular Strength

The muscular strength phase, consisting of progressive resisted ROM and initial closed chain therapeutic exercises, is generally introduced 3 to 4 weeks after the initiation of the muscular endurance phase (approximately 8–12 weeks postoperatively), as long as the patient has met the criteria for progression (see Fig. 10A.1 ) and the introduction agrees with physician direction and tissue healing timelines. The therapist and surgeon need to be confident that adequate healing has occurred to withstand progressively applied loads of resistive strengthening.

The goal of this phase is to enhance muscular strength and general upper extremity function while continuing to improve functional ROM as needed. Strengthening should be initiated with light resistance band and/or light dumbbell isotonic exercises as well as functionally based, initially closed chain stabilization and scapular stabilization exercises. All exercises are performed with the underlying goal of improving the strength of the rotator cuff musculature, ensuring that proper force couples are established while maintaining normal scapulohumeral rhythm.

Initial resistance can be applied by adding light dumbbells or resistance bands to the nonresisted isotonic exercises described in the muscular endurance phase. The patient can also begin light resisted isotonic exercises at and/or below shoulder height with resistance bands, which provide both a concentric and an eccentric component. The internal and external rotators of the glenohumeral joint are typically strengthened in a standing position with use of various angles of abduction and forward elevation as progressions. Forward punches to 90 degrees of glenohumeral elevation with a “plus” is begun to commence serratus strengthening as well as to improve functional strength above waist level. The standing row exercise strengthens the middle trapezius and rhomboids, like the prone row exercise described by . The lower trapezius muscle has been shown to exhibit the largest electromyographic activity with the prone full can exercise ( ). Resisted triceps and biceps work can also be incorporated into this phase, beginning with light dumbbell or band resistance and progressing as appropriate. Proper scapular position and normal scapulohumeral kinematics should be emphasized with all resisted exercise throughout this phase in order to achieve proper glenohumeral kinematics with a resisted load.

Initial closed chain exercises are also begun in this phase to improve neuromuscular control, muscular strength, and proprioception of the glenohumeral joint. Closed chain exercises have been shown to increase compressive forces through the glenohumeral joint, resulting in greater muscle activation and stabilization ( ). Closed chain exercises are initiated in the standing position with the hands on a wall, then progressively advanced to a declined position and then quadruped and plank positions. Closed chain activities consist of weight shifts, static holds with and without manual perturbations to promote rhythmic stability, scapular protraction/retraction, double arm to single arm support, and initial push-ups.

If the patient’s functional demands do not consist of repetitive overhead or power movements, the muscular strength phase may be his or her final stage of rehabilitation before discharge from physical therapy. In order for a patient who needs to progress to the muscular power phase to do so, criteria regarding strength, function, and ROM must be met (see Fig. 10A.1 ) The muscular power phase is used for patients who require their shoulders to function at a higher level, including those whose occupation requires repetitive or heavy overhead activity as well as recreational and competitive athletes.

Phase IV: Muscular Power

In order to transition to the muscular power phase, the patient must have a manual muscle test grade of 5/5 in all planes of glenohumeral range of motion on the repaired side or must demonstrate more than 90% of the strength of the uninvolved upper extremity on a handheld dynamometer test. The muscular power phase consists of advanced band and weight resistance, advanced closed chain and rhythmic stabilization, and plyometric exercises. The purpose of this phase is to prepare the patient for return to demanding occupation-specific or sport-specific activities. At this point in rehabilitation, the patient is expected to have full active ROM and may be given a home program consisting of stretching and mobility work as needed. Repetitions and sets of each exercise should be adjusted according to the American College of Sports Medicine (ACSM) recommendations most appropriate for each patient’s rehabilitative goal ( ). In this phase, resistance band exercises should progress to external and internal rotation at 45 and 90 degrees of abduction in order to improve muscle function in overhead positions. Closed chain stabilization exercises are progressed to advanced push-ups with plus on stable and variable surfaces; resisted proprioceptive neuromuscular facilitation, deceleration, and plyometric exercises are also introduced. Deceleration and plyometric exercises should focus on the posterior cuff musculature combined with trunk stabilization. Plyometric activity has been shown to improve force production of the elbow extensors and activation of the scapulothoracic musculature ( ).