EVIDENCE BASED REHABILITATION OF ROTATOR CUFF INJURY.pptx

Physiotherapy management of ROTATOR CUFF TEARS.

1. Presented by Neetu Bargayary MPT 3 rd SEM Roll no – 2024/MPT/OOO4 EVIDENCE BASED REHABILITATION OF ROTATOR CUFF INJURY

2. Introduction The rotator cuff is a group of muscles ( supraspinatus , infraspinatus , teres minor, and subscapularis ) in the shoulder that enable a broad range of motion while preserving the stability of the glenohumeral joint. Rotator cuff injury (RCI) is a common musculoskeletal problem that can have a significant impact on the QOL & functional abilities of those affected. It accounts for 50% of all shoulder disorders & is prevalent in 15-30% of the world population. Mainly seen in older adults & athletes & is more common in men.

3. Causes & Clinical features CAUSES Due to degenerative changes in shoulder (in old age) Due to repetitive shoulder movements In cases of trauma like RTA, fractures or dislocation of the shoulder joint CLINICAL FEATURES Pain Tenderness Arm weakness Inability to sleep on the affected shoulder Joint stiffness Scapular winging Atrophy of muscles

4. Assessment Subjective asessment Age – More common in active young adults & ages 60 or more Gender – More common in men Occupation – Jobs requiring repetitive overhead arm motions like carpentry, house painting, weight lifting, etc Chief complaints – Pain, fatigue, arm weakness Onset of symptoms – Gradual Pain – Present at front of shoulder Dull ache type Aggravates at night or overhead activities Objective assessment General observation of posture ROM – may be altered Strength – weakness Palpation – tenderness at the front of shoulder Special tests –

5. SUBSCAPULARIS TEST – Internal rotation TEST DESCRIPTION POSITIVE TEST LIFT OFF TEST With arm in IR patient places dorsum of hand against their back & tries to lift the hand against therapists resistance. Inability to lift hand against resistance BELLY PRESS TEST (Abdominal compression test) With the elbow flexed to 90 degrees the patient places the palm of their hand on their abdomen. The therapist tries to pull the patients arm out & the patient tries to maintain the internal rotation of shoulder Inabily to maintain the internal rotation position Compensation by adduction of shoulder or flexion of wrists BEAR HUG TEST The patient reaches their opposite (good) shoulder with their palm placed on to it. The therapist tries to resist the internal rotation of shoulder by attempting to pull it & patient tries to maintain the internal rotation. Inability to hold the hand against shoulder

6. SUPRASPINATUS TEST –Abduction TEST DESCRIPTION POSITIVE TEST JOBE’S TEST (Empty can test) Patient raises arm to 90 degree in scapular plane with the thumbs down. Therapist applies downward pressure. Pain or weakness DROP ARM TEST (Drop sign) From 90 degree abduction of arm the patient is asked to lower the arm slowly. Immediate drop of arm accompanied with pain

7.  INFRASPINATUS & TERES MINOR TEST – External rotation TEST DESCRIPTION POSITIVE TEST EXTERNAL ROTATION LAG SIGN Thepapist passively flexes the patient’s elbow at 90 degrees , while the shoulder is elevated to 20 degrees in scapular plane. One hand supporting the elbow and the other hand supports the wrist. Then he/she removes their hand from the wrist & ask the patient to maintain this position. Inability to hold the position or arm drop

8. Treatment RCT can be classified into 2 main types – Partial thickness tears (less than 50% tears) – treated conservatively Complete/full thickness tears (50% & above tears) – treated surgically using Open repair Arthroscopic repair (most common) Tendon transfers for severely damaged tendons Reverse shoulder replacement for massive tears.

9. Evidence based rehabilitation of rotator cuff tear Phase I – Acute Phase Phase II – Intermediate Phase Phase III – Advanced Strengthening Phase Phase IV – Return to Activity Phase

10. PHASE 1 (1-6 weeks) GOALS PROTOCOL EXERCISES DOSE Criteria for progression to phase III Promote t issue healing Reduce pain & inflammation Protection of RC Painless near-normal ROM Strict immobilization using an arm sling.(2-3 weeks for partial tears & up to 6 weeks for full thickness tear Elbow, hand & wrist active motion External rotation in the scapula r plane should not exceed 45 degree Move from PROM to AAROM at 4–6 weeks. Electrical stimulation & cryotherapy as needed Active wrist & elbow ROM Hand grip with putty Pendulums Passive & active assisted flexion, scaption , internal & external rotation Shoulder isometrics at 0-45 degree abduction . 3 x 15 reps, daily Minimal pain or inflammation N ear-normal ROM Baseline muscular strength without fatigue.

11. Fig – Scaption (without ball/weights) Fig – Shoulder isometrics at 45 degree abduction

12. PHASE 2 (6-12 weeks) GOALS PROTOCOL EXERCISES DOSE Criteria for progression to phase III Restore ROM Initiate active muscle contractions with a focus on regaining proper scapula humeral rhythm Training in joint proprioception Progress from AAROM to AROM Phase 1 exercises Internal rotation and posterior capsule stretches AROM exercises, progressed from supine to partial sitting to standing . Initiate exercise in water (Hydrotherapy) if available. Scapular strengthening with rows/shrugs/ punches Two-handed plyometrics 3 x 15 reps, daily Full, pain-free ROM Full 5/5 strength without fatigue

13. Fig – Internal rotation & sleeper stretch to stretch posterior capsule

14. Fig – Scapular strengthening with rows

15. Fig – Scapular strengthening punches (without weight, with less weight & progress accordingly)

16. Fig – Two handed plyometrics (Chest pass, overhead throw & side-to-side throw)

17. PHASE 3 (12-14 weeks) GOALS PROTOCOL EXERCISES DOSE Criteria for progression to phase IV Restore full AROM Progress strengthening & scapular stabilization exercises Initiate more functional drills into the rehabilitation program Strengthening & endurance ROM exercises to maintain full range Phase 2 exercises, increase intensity/sets/ repetitions Functional drills Push-up progression Theraband external rotation in the 90/90 position Prone therapeutic exercises 3 x 15 reps, daily Minimal pain or tenderness Full ROM & strength Adequate proprioception , & dynamic stability.

18. Fig – Prone therapeutic exercises

19. PHASE 4 (14-24 weeks) GOALS PROTOCOL EXERCISES DOSE PROGRESSION Build full functional strength Implement functional or sport specific training Establish a progressive gym program Strengthening Phase 3 exercises Closed chain weight shift using tilt board One-handed plyometric exercises One arm ball tosses Wall ball dribbling Alternating shoulder taps ( Plyometric push-ups) Eccentric rotator cuff strengthening Large muscle exercises 3 x 15 reps, daily Return to play is permitted after the athlete regains full pain-free shoulder ROM, preinjury shoulder strength & clinical/sport-specific testing.

20. Fig – Closed chain weight shift using tilt board Fig – Wall ball dribble

21. Recent advances A study was done by Fabio V. Sciarretta et. al. on the Current trends in rehabilitation of rotator cuff injuries which concluded that early motion improves the ROM in the short & mid-term, allowing faster recovery. Another study done by Neha Reyalch et. al. on Exploring Recent Advancements inRotator Cuff Injury Rehabilitation:A Narrative Review concluded that ultrasound-guided electrical stimulation combines real-time ultrasound imaging with electrical stimulation, ensuring targeted and safe treatment delivery. Another study done by Alexandre Lädermann et. al. on Hydrotherapy after Rotator Cuff Repair Improves Short-Term Functional Results Compared with Land-Based Rehabilitation When the Immobilization Period Is Longer concluded that Hydrotherapy was more efficient compared to land-based therapy.

22. References Alexandre Lädermann et. al. Hydrotherapy after Rotator Cuff Repair Improves Short- TermFunctional Results Compared with Land-Based RehabilitationWhen the Immobilization Period Is Longer. J. Clin. Med. 2024, 13, 954 Neha Reyalch et. al. Exploring Recent Advancements inRotator Cuff Injury Rehabilitation:A Narrative Review. Journal of Clinical and Diagnostic Research. 2024 May, Vol-18(5): KE01-KE05 Sajjad Ali Gill et al. Rehabilitation of Rotator Cuff Acute & Chronic injury in Throwing Sports athletes (Cricket & Baseball) through Theraband & Hydrotherapy Exercises plus Treatment & Diagnosis Evaluation. Human Nature Journal of Social Sciences Vol.4, No.1 (March, 2023), Pp.74-89 Teresa Paolucci et. al. Comparison of Early versus Traditional Rehabilitation Protocol after Rotator Cuff Repair: An Umbrella-Review. Journal of Clinical Medicine (2023) Anna K. Reinholz et. al. Advances in the Treatment of Rotator Cuff Tears: Management of Rotator Cuff Tears in the Athlete. Clin Sports Med. 2023

23. Rebecca N. Dickinson et. al. Non-operative Treatment of Rotator Cuff Tears. Phys Med Rehabil Clin N Am 34 (2023) 335–355 Taylor Swansen et. al. Postoperative Rehabilitation Following Rotator Cuff Repair. Phys Med Rehabil Clin N Am 34 (2023) 357–364 Fabio V. Sciarretta et. al. (2023) Current trends in rehabilitation of rotator cuff injuries. SICOT-J 2023, 9,14 Todd May et. al. Rotator Cuff Injury. National Library of Medicine. Jun 26, 2023. Sameer R. Oak et. al. (2022) Rehabilitation and Return to Play of the Athlete after an Upper Extremity Injury. Arthroscopy, Sports Medicine, and Rehabilitation, Vol 4, No 1 (January), 2022: pp e163-e173 Sajjad Ali Gill et. al. (2022) Diagnosis, Treatment & Rehabilitation of Rotator Cuff Acute & Chronic Injury in Throwing Sports Athletes by Isometric, Isotonic and Theraband Exercises. Journal of Pharmaceutical Research International Volume 34, Issue 60, Page 12-20, 2022; Article no.JPRI.95141 Brukner & Khan’s Clinical Sports Medicine – 4 th Edition

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