Rotator Cuff Tears
Rotator cuff tears and subacromial impingement are among the most common causes of shoulder pain and disability. The frequency of rotator cuff tears increases with age, with full-thickness tears uncommon in patients younger than 40 years. The rotator cuff “complex” refers to the tendons of four muscles: subscapularis, supraspinatus, infraspinatus, and teres minor. These four muscles originate on the scapula, cross the GH joint, then transition into tendons that insert onto the tuberosities of the proximal humerus. The rotator cuff has three well-recognized functions: rotation of the humeral head, stabilization of the humeral head in the glenoid socket by compressing the round head into the shallow socket, and the ability to provide “muscular balance,” stabilizing the GH joint when other larger muscles crossing the shoulder contract. Injury to the rotator cuff may occur in progressive stages (see box p. 149). Rotator cuff tears can be classified as either acute or chronic, based on their timing, and as partial (articular or bursal side) or complete, based on the depth of the tear. Complete tears can be classified based on the size of the tear in square centimeters as described by Post (1983): small (0–1 cm2), medium (1–3 cm2), large (3–5 cm2), or massive (>5 cm2). All these factors, as well as the patient’s demographic and medical background, play a role in determining the treatment plan.
Surgical repair of a torn rotator cuff is done in an effort to decrease pain, increase function, and improve ROM. Postoperative care must strike a precarious balance between restrictions that allow for tissue healing, activities that return ROM, and gradual restoration of muscle function and strength. It is not uncommon to have residual postoperative stiffness and pain despite an excellent operative repair if the postop rehabilitation is not correct.
Wilk and Andrews described multiple factors that significantly affect the postoperative rehabilitation program after repair of rotator cuff tears.
Type of Repair
Patients who have had deltoid muscle detachment or release from the acromion or clavicle (e.g., traditional open rotator cuff repair) may not perform active muscle contractions of the deltoid for 6 to 8 weeks. This is avoided to prevent avulsion of the deltoid.
Arthroscopic repair of the cuff actually has a slightly slower rate of rehabilitation progression owing to the weaker fixation of the repair compared with that of the open procedure. A mini-open procedure, involving a vertical split with the orientation of the deltoid fibers, allows mild, earlier deltoid muscular contractions. Regardless of the surgical approach performed, the underlying biology of healing tendons must be respected for all patients.
Size of the Tear
Functional outcome and expectation after rotator cuff surgery are directly related to the size of the tear repaired. Wilk and Andrews (2002) base the rate of rehab on the size and extent of the tear (see Rehabilitation Protocol, p. 184).
Tissue Quality
The quality of the tendon, muscular tissue, and bone helps determine speed of rehabilitation. Thin, fatty, or weak tissue is progressed slower than excellent tissue.
Location of the Tear
Tears that involve posterior cuff structures require a slower progression in external rotation strengthening. Rehabilitation after subscapularis repair (anterior structure) should limit resisted internal rotation for 4 to 6 weeks. Restriction of the amount of passive external rotation motion should also be restricted until early tissue healing has occurred. Most tears occur and are confined to the supraspinatus tendon, the critical site of wear, often corresponding to the site of subacromial impingement.
Onset of the Rotator Cuff Tear and the Timing of the Repair
Acute tears with early repair may have a slightly greater propensity to develop stiffness, and we are a little more aggressive in the ROM program. Cofield (2001) noted that patients who underwent an early repair progressed more rapidly with rehabilitation than those with a late repair.
Patient Variables
Several authors have reported a less successful outcome in older patients than young. This may be due to older patients’ typically having larger and more complex tears, probably affecting outcome.
Several studies have noted no difference in outcome based on arm dominance. Hawkins and associates (1991) noted that worker’s compensation patients required twice as long to return to work compared with their non–worker’s compensation cohorts.
Finally, researchers have noted a correlation between preoperative shoulder function and outcome after surgical repair. Generally, patients who have an active lifestyle before surgery return to the same postop.
Rehabilitation Situation and Surgeon’s Philosophic Approach
We recommend treatment with a skilled shoulder therapist rather than a home therapy program. Lastly, some physicians prefer more aggressive progression, whereas others remain very conservative in their approach.
Rehabilitation after rotator cuff surgery emphasizes immediate motion, early dynamic GH joint stability, and gradual restoration of rotator cuff strength. Throughout rehabilitation, overstressing of the healing tissue is to be avoided, striking a balance between regaining shoulder mobility and promoting soft tissue healing.
Acute Tears
Patients with acute tears of the rotator cuff usually present to their physician after a traumatic injury. They have complaints of pain and sudden weakness, which may be manifested by an inability to elevate the arm. On physical examination, they have a weakness in shoulder motion of forward elevation, external rotation, or internal rotation depending on which cuff muscles are involved. Passive motion is usually intact depending on the timing of presentation. If the injury is chronic and the patient has been avoiding using the shoulder because of pain, there may be concomitant adhesive capsulitis (limitation of passive shoulder motion) and weakness of active ROM (underlying rotator cuff tear).
Radiographs
A standard radiologic evaluation or “trauma shoulder series” should be obtained, including an anteroposterior (AP) view in the plane of the scapula (“true AP” of GH joint) (Fig. 3–54), a lateral view in the plane of the scapula (Fig. 3–55), and an axillary lateral view (Fig. 3–56). These radiographs help to eliminate other potential pathologic entities such as a fracture or dislocation. MRI can provide direct imaging of the rotator cuff, helping to confirm the clinical diagnosis.
It is important to remember that the likelihood of an associated rotator cuff tear with a shoulder dislocation increases with age. In patients older than 40 years of age, an associated rotator cuff tear is present with shoulder dislocation in more than 30%; in patients older than 60 years, it is present in more than 80%. Therefore, serial examinations of the shoulder are necessary after a dislocation to evaluate the integrity of the rotator cuff. If significant symptoms of pain and weakness persist after 3 weeks, an imaging study of the rotator cuff is required. A torn rotator cuff after a dislocation is a surgical problem, so once the diagnosis is made, surgical repair is indicated.
Treatment
The recommended treatment for active patients with acute tears of the rotator cuff is surgical repair. Advantages of early operative repair include mobility of the rotator cuff, which allows technically easier repairs, good quality of the tendon, which allows a more stable repair, and in the patients with cuff tears associated with a dislocation, the repair will improve GH joint stability.
Chronic Tears
Chronic rotator cuff tears may be an asymptomatic pathologic condition that has an association with the normal aging process. A variety of factors, including poor vascularity, a “hostile” environment between the coracoacromial arch and the proximal humerus, decreased use, or gradual deterioration in the tendon, contribute to the senescence of the rotator cuff, especially the supraspinatus. Lehman and colleagues (1995) found rotator cuff tears in 30% of cadavers older than 60 years and in only 6% of those younger than 60 years. In a study by Romeo and coworkers (1999), the average age of their patients treated for a rotator cuff tear was 58 years. Many patients with a chronic rotator cuff tears are over the age of 50 years, have no history of shoulder trauma, and have vague complaints of intermittent shoulder pain that has become progressively more symptomatic. These patients may also have a history that is indicative of a primary impingement etiology.
Examination
On physical examination, some evidence of muscular atrophy may be seen in the supraspinatus fossa.
Depending on the size of the tear, there may also be atrophy in the infraspinatus fossa.
Passive motion is usually maintained, but may be associated with subacromial crepitance.
Smooth active motion is diminished, and symptoms are reproduced when the arm is lowered from an overhead position.
Muscle weakness is related to the size of the tear and the muscles involved.
A subacromial injection of lidocaine may help to differentiate weakness that is caused by associated painful inflammation from that caused by a cuff tendon tear.
Provocative maneuvers including the Neer impingement sign (see Fig. 3–19) and the Hawkins sign (see Fig. 3–20) may be positive but are nonspecific because they may be positive with other conditions such as rotator cuff tendinitis, bursitis, or partial-thickness rotator cuff tears.
It is important that other potential etiologies be investigated. Patients with cervical radiculopathy at the C5–6 level can have an insidious onset of shoulder pain, rotator cuff weakness, and muscular atrophy in the supraspinatus and infraspinatus fossa.
Imaging
Imaging studies may be helpful in confirming the diagnosis of a chronic rotator cuff tear and may help to determine the potential success of operative treatment.
A “trauma shoulder series” (p. 172) may show some proximal (superior) humeral migration, which is indicative of chronic rotator cuff insufficiency.
Plain radiographs can also show degenerative conditions or bone collapse consistent with a cuff tear arthropathy in which both the cuff deficiency and the arthritis contribute to the patient’s symptoms.
An MRI examination of the shoulder may help to demonstrate a rotator cuff tear, its size, and degree of retraction. The MRI can also help assess the rotator cuff musculature. Evidence of fatty or fibrous infiltration of the rotator cuff muscles is consistent with a long-standing cuff tear and is a poor prognostic indicator for a successful return of cuff function.
Ultrasound and double-contrast shoulder arthrography are additional studies that are occasionally used to diagnose rotator cuff tears, but are less helpful for determining the age of the tear.
Treatment
Treatment of most patients with a chronic tear of the rotator cuff follows a conservative rehabilitation program. Operative intervention in this patient population is indicated for patients who are unresponsive to conservative management or demonstrate an acute tearing of a chronic injury. The primary goal of surgical management of rotator cuff tears is to obtain pain relief. Additional goals, which are easier to achieve with acute rotator cuff tears than chronic rotator cuff tears, include improved ROM, improved strength, and return of function.
Rotator Cuff Tears in Overhead Athletes
Overhead athletes are at an increased risk for rotator cuff injuries because of the repetitive, high velocity, mechanical stresses placed on their shoulders. Those athletes who have an underlying degree of instability may experience compression of the cuff as well as the posterior-superior glenoid labrum along the upper third of the posterior glenoid. This condition, known as internal impingement, is a contributing factor to the development of articular-sided partial-thickness tears and full-thickness tears in overhead athletes.
Successful treatment of this patient population depends on the recognition of the underlying instability.
The diagnosis requires a comprehensive history focusing on the timing and quality of the pain and a complete physical examination performing provocative maneuvers that test for instability.
Radiologic evaluation with an arthrogram-enhanced MRI may identify partial-thickness tears.
In this population, patients with partial-thickness tears rarely require operative repair because of resolution of symptoms after proper shoulder rehabilitation (see p. 174) and/or an operative stabilization procedure.
Overhead athletes diagnosed with a full-thickness rotator cuff tear in the setting of anterior instability should be treated aggressively with surgical repair of the rotator cuff and a stabilization procedure. This recommendation is at odds with historical recommendations for older patients to treat the rotator cuff tear, then evaluate the need for additional treatment of the instability.
Maximal athletic performance requires an intact rotator cuff and a stable shoulder.
Aggressive débridement of partial-thickness tears is discouraged because of the risk of thinning of the tendons and propagation to a full-thickness tear.
Rehabilitation for patients with partial tears treated nonoperatively is similar to the program on p. 174. Patients treated with operative stabilization procedures follow the postoperative routine on p. 203, and patients who have an associated cuff repair follow the rehabilitation on p. 183. Once the overhead athlete has completely healed the repair, recovered full ROM and a significant amount of strength, he or she can advance to the sport-specific rehabilitation program (see Interval Throwing section).
Rehabilitation after Arthroscopically Assisted Mini-open Repair of the Rotator Cuff
We use three different rehabilitation programs based on the size of the tear and the condition of the repaired tissues (Table 3–5). The three programs differ mainly in their rates of progression:
The type 1 program is used for small tears in younger patients with good to excellent tissues. This program is much more progressive than type 2 or 3.
The type 2 program is used for medium to large tears in active individuals with good tissues.
The type 3 program is used for patients with large to massive tears with a tenuous repair and fair to poor tissue quality.
Important General Points for Rehabilitation after Rotator Cuff Repair
Reestablishing early passive ROM is considered paramount.
On postoperative day 1, the patient’s arm is passively moved through a ROM (flexion in the scapular plane and internal and external rotation in the scapular plane at 45 degrees of abduction).
Allow active-assisted external and internal rotation with L-bar (Breg Corp., Vista, Calif) in the scapular plane (Fig. 3–60). The patient moves the arm to tolerance but no farther and gently progresses ROM over subsequent days.
Active-assisted arm elevation with the L-bar in the scapular plane is allowed at 7 to 10 days. The therapist must provide assistance or support as the patient lowers the arm from 80 to 30 degrees of elevation or the patient will have pain secondary to his or her inability to control the arm while lowering it.
As motion progresses, exercises are done with the arm abducted to 75 degrees during external and internal rotation active-assisted ROM stretching.
The patient is then progressed to 90 degrees of abduction for these ROM exercises.
Finally, the arm is placed at the side (0 degrees of abduction) during external and internal rotation.
Goals for obtaining full passive motion of the shoulder after rotator cuff repair
Type 1—3–4 wk
Type 2—4–6 wk
Type 3—6–8 wk
The restoration of active motion is much slower because of healing constraints, pain inhibition, and weakness of the rotator cuff.
Motions such as excessive shoulder extension, adduction behind the back, and horizontal adduction are prohibited for at least 6 to 8 weeks.
Cryotherapy is used four to eight times a day for the first 7 to 10 days to suppress inflammation, decrease muscle spasm, and enhance analgesia.
Active submaximal, pain-free multiangle isometrics are used for the internal and external rotators, abductors, flexors, and elbow flexor muscle groups.
Rhythmic stabilization exercises (in the supine position) are begun at 10 to 14 days postoperative (type 2 protocol) to restore the dynamic stabilization of the GH joint through cocontractions of the surrounding musculature. These exercises are designed to prevent and treat the “shrug” sign (Fig. 3–61).
These exercises are done in the “balanced position,” defined as 100 to 110 degrees of elevation and 10 degrees of horizontal abduction (Fig. 3–62).
In this position, the therapist provides an extremely low (3–4 pounds of force) isometric force to resist flexion and extension and horizontal abduction and adduction.
The “balanced position” (100–110 degrees of elevation) is used so that the deltoid muscle generates a more horizontal (and thus compressive) force (Fig. 3–63). This exercise at 100 to 125 degrees activates the rotator cuff with assistance from the deltoid to avoid superior migration of the humeral head.
The shrug sign occurs with a strong deltoid muscle overpowering the weakened rotator cuff, causing the humeral head to superiorly migrate (see Fig. 3–42). This is related to a lack of humeral head control. At initiation of arm elevation to 25 to 30 degrees, the entire shoulder elevates or “shrugs.” Dynamic stabilization drills should alleviate this.
As GH joint control is regained and reestablished, the drills can be done at lower flexion angles (30, 60, 90 degrees). The progression is (1) supine (scapula support) to (2) side-lying (Fig. 3–64), and then (3) seated.
Rhythmic stabilization drills (low 3- to 4-pound force) are done for the internal and external rotators in the plane of the scapula (start at 7 to 10 days) (Fig. 3–65).
At 3 weeks, isotonic tubing is used for external and internal rotator muscles with the arm at the side (see Fig. 3–39). As strength improves, side-lying external rotator strengthening is begun. External rotation strength is emphasized.
Emphasis is on external rotation strength because this strength is critical in reestablishing functional use of the arm.
The patient is not allowed to progressively exercise through a shrug sign (deleterious to the repair). Emphasis should be on reestablishing dynamic stabilization.
Once external rotation strength is achieved, active abduction and flexion are allowed.
At 8 weeks, light isotonic strengthening and flexibility exercises are begun, with low weight and high repetition for muscle endurance and strength.
At 3 months, the patient can progress to the fundamental shoulder exercise program (see p. 169).
Tennis players
Ground strokes are allowed at 5 to 6 months.
Serving is allowed when pain-free (10 to 12 months).
Interval training tables are on p. 193.
Golfers
Golf swing is begun at 16 weeks.
Gradual return to play is allowed at 6 to 7 months.
Interval training figures are on p. 195.
Internal training programs for overhead athletes should be employed after periods of prolonged inactivity or after the surgically repaired athlete has healed and is cleared to play. These programs encourage a gradual resumption of activity rather than immediate full velocity throwing that may produce injury (see Interval Throwing section).
Patients with arthroscopic repairs are generally progressed 2 to 3 weeks slower than those with arthroscopically-assisted mini-open procedures because the fixation is not as strong.
Rehabilitation after Débridement of Irreparable or Massive Rotator Cuff Tears
The rehabilitation program for patients with “irreparable” massive rotator cuff tears with arthroscopic subacromial decompression and rotator cuff débridement focuses on four critical treatment areas:
Gradual attainment of motion through passive and active-assisted stretching techniques. Full motion should be obtained by 3 to 4 weeks after surgery.
Gradual restoration of shoulder strength, beginning with the rotator cuff and scapulothoracic muscles (Fig. 3–66), then progressing to the deltoid muscles.
Reestablishment of “balance of muscular forces” at the GH joint to allow arm elevation.
The key to restoring active shoulder elevation in these patients is strengthening of the posterior rotator cuff muscles.
Burkhart (2001) reported that weakness of the posterior rotator cuff otherwise “uncouples” the force couple, leading to anterior-superior translation of the humeral head with active arm elevation.
Restoration of dynamic stability to the GH joint through proprioceptive and neuromuscular training drills.
Internal and external rotation rhythmic stabilization drills are done at various degrees of nonpainful arm elevation (see Fig. 3–65).
External rotation is strengthened with light isotonic and isometric exercises.
Patients should continue their preinjury exercise programs three times a week or more. The fundamental shoulder exercise program is continued (see p. 169).
|
