Rotator Cuff Repair
Most repairs are now performed arthroscopically so there is less tissue trauma and reduced risk of adhesions. Post-op stiff shoulder is now rarely a problem, so the priority is to protect the repair from breaking down.
Always be guided by the patient's pain. Do not force, stretch or stress the repair before 6 weeks
Protocol selection will be determined not just by the size of tear, but also the shape of the tear, strength of repair and general tissue & joint condition. Always check with the Consultant.
Educate patients about basic rotator cuff function and lever principles to reduce the risk of stressing the repair prematurely.
Patients are in a sling for 6 weeks and should not drive for 6 to 8 weeks.
(1) MINOR (small): Less than 1 cm
Day 1 ・2 Weeks
Mastersling with body belt
Wrist exercises
Elbow exercises
Shoulder girdle
Initiate scapula setting
Begin pendular exercises
3 Weeks ・Review by Consultant
Commence Physiotherapy. DO NOT FORCE OR STRETCH
Wean off sling (may be delayed till 6 weeks)
Continue pendular exercises
Progress passive flexion in scapular plane and external rotation to neutral
Progress to assisted flexion, extension, abduction as is comfortable ・internal and external rotation to neutral only.
Initiate gentle cuff isometric exercises as pain allows
Encourage normal function around waist level
May begin active exercises if appropriate - ONLY IF GUIDED BY THE CONSULTANT
Can start driving (guided by Consultant)
6 Weeks
Continue active exercises progressing into range
Commence anterior deltoid exercises as range allows
Commence rotator cuff strengthening and closed chain exercises
Start stretching limited movements
Encourage functional movement within pain limits
Begin gentle hydrotherapy if available
Proprioceptive exercises and core stability work as appropriate
(2) MEDIUM: 1cm ・3cms
Day 1 to 3 Weeks
Mastersling with body belt plus abduction pad
Wrist, hand and finger exercises
Elbow exercises
Shoulder girdle
Initiate scapular setting
3 Weeks ・Review by Consultant
Abduction pad removed, unless otherwise stated by Consultant
Sling retained
Begin pendular exercises
4 to 5 Weeks
Start physiotherapy. DO NOT FORCE OR STRETCH
Passive flexion in scapular plane + external rotation
Initiate gentle cuff isometrics as pain allows
Progress when comfortable to assisted exercises
Begin hydrotherapy if available
6 Weeks
Wean out of sling
Begin active exercises. Encourage functional movements at waist level
Anterior deltoid strengthening exercises as range of movement allows
Progress range adding resistance as appropriate
Start rotator cuff strengthening progressively, dependent on pain
Add closed chain exercises
Begin proprioceptive skills
8 Weeks
Start driving
(3) MAJOR (large): 3cms ・5cms
MASSIVE: greater than 5 cms
Day 1 to 3 Weeks
Mastersling with body belt plus abduction pad
Wrist and finger exercises
Elbow exercises
Shoulder girdle
Initiate scapula setting
3 Weeks - Review by Consultant
Abduction pad retained, unless otherwise stated by Consultant
Sling retained
Begin pendular exercises as instructed
6 Weeks
Remove abduction pan if not already done so
Commence physiotherapy. DO NOT FORCE OR STRETCH
Wean out of sling slowly
Passive flexion etc
Gentle rotator cuff isometrics, pain limiting
Begin assisted exercises
Gradually progress to active exercises
Begin hydrotherapy
Encourage normal function around waist level
8 Weeks
Start stretching if appropriate
Add resisted exercises within pain limits
Start rotator cuff strengthening
Anterior deltoid strengthening as range of movement allows
Add closed chain exercises
Begin proprioceptive skills
Encourage functional movement within pain limits
Start driving if comfortable
Consideration should always be given to the individual patients' ability. The protocol is based on maintaining range of movement in the first phase and then gradually building strength in the middle to last phase. Progression should be tailored to the individual patient but the times quoted should be the earliest for active movement and when strengthening (resisted exercises) begins.
Return to Functional Activities
These are approximate and will differ depending upon the individual.
However, they should be seen as the earliest that these activities may commence.
Note: These are guideline protocols only.
Manipulation Under Anaesthetic (MUA)
/ Arthroscopic Release of Shoulder Contracture
An MUA and/or Arthroscopic release are performed for primary frozen shoulder (adhesive capsulitis), but not usually in the acute phase. Arthroscopic release is performed for post traumatic (post fracture) and post surgical stiffness.
The operation is performed under general anaesthetic with injection of local anaesthetic and steroid into the joint. Full range of motion is achieved operatively unless otherwise stated.
The procedure is done as a day case except where the patient has diabetes or other systemic problems where overnight stay may be indicated.
Protocol
The patient is seen prior to discharge by the physiotherapist when passive and active range of motion is begun. It is important that the joint is taken through all planes of movement.
The patient is discharged with exercise and advice on pain control.
A physiotherapy appointment must be pre-arranged for the following day.
Aims of Physiotherapy
Restore FULL range of movement as quickly as possible through passive and active assisted exercise, maintain this range
Encourage resumption of ADL immediately.
Exercising in water is particularly beneficial
Strengthen rotator cuff as appropriate
3 Weeks
The patient attends for review at the Reading Shoulder Surgery unit
The patient will continue with physiotherapy if indicated.and is usually discharged at this stage.
3 Months
The patient attends for review at the Reading Shoulder Surgery unit and is usually discharged at this stage.
Return to Functional Activities
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Driving 1 week
-
Return to Work Dependant on the patient's occupation
-
Golf 6 weeks, (but not driving range)
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Racquet Sports Sport specific training when comfortable Competitive play after 3 months
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Lifting as able
Copeland Surface Replacement Arthroplasty of the Shoulder
Introduction
This operative procedure is performed in cases of severe Osteo or Rheumatoid arthritis
where pain is the predominant feature.
The hemi arthropalsty is the usual method of choice.
Early mobilisation is encouraged.
As subscapularis is released and reattached to the anatomical neck of humerus at the
end of the procedure, there should be no resisted internal rotation for the first three
weeks and care should be taken with the range of external rotation.
Pre op
Patient assessment
Patient's Constant score recorded
Information given
Post op
Day 1
Mastersling with body belt fitted in theatre
Cryocuff to reduce inflammation
Finger, wrist and radio ulnar movements
Active elbow flexion and extension
Shoulder girdle exercises and postural awareness
Day 2 ・Day 3-5 (Discharge)
Body belt removed
Axillary hygiene taught
Continue using cryocuff
Exercises continue as above
Hand gripping exercise
Pendular exercises
Passive flexion/extension in scapular plane in supine
Continue with shoulder girdle exercises, postural awareness and include scapular setting .
Discharge (Day 3-5) to 3 Weeks
Remove sling when comfortable
Pendular exercises continued
Isometric strengthening exercises of all muscle groups (except IR)
Begin passive abduction (maintain shoulder in IR)
Begin passive external rotation to neutral only.
Begin active assisted flexion in supine and progress to sitting position as soon as the patient is able. Progress to active when possible.
Encourage relaxation and breathing control
Hydrotherapy may begin if available
3 Weeks to 6 Weeks
Encourage the patient to actively move into all ranges. Gentle assisted stretching exercise to increase range - do not force inner range ER
Add isometric IR ・sub maximally and only if painfree
Commence isometric theraband exercises - resistance dependant on individual
N.B. Take care with IR
Progress to isotonic strengthening
Encourage proprioceptive exercises-weight and non weight bearing
6 Weeks
Progress strengthening and include anterior deltoid exercises
Continue to regularly stretch the joint to end of its available range
Can begin breaststroke if pain and range of movement allows
How well the patient progresses and the outcome will depend on the condition of the joint and soft tissues preoperatively. A better outcome is expected with patients whose joint is replaced for primary OA. Improvement continues for 18 months to 2 years and where possible the patient should not be discharged or should continue exercising until their maximum potential has been reached. The protocol outlined applies to patients with an intact rotator cuff. If a rotator cuff repair has been carried out in addition to the above procedure, the therapist should adhere to the strengthening protocol for the repair.
Return to Functional Activities
These are approximate and may differ depending upon each patient's individual achievements. However, they should be seen as the earliest that these activities may commence.
Stemmed Hemiarthroplasty for fracture
Post op
Day 1
Mastersling with body belt fitted in theatre
Cryocuff to reduce inflammation
Finger, wrist and radio ulnar movements
Active assisted elbow flexion and extension
Teach axillary hygiene
Hand gripping exercises
Shoulder girdle exercises and postural awareness Continue the exercises above for 3 weeks at which time the patient will be reviewed at The Shoulder Unit.
3 Weeks
Body belt removed
Commence pendular exercises
Continue with shoulder girdle exercises, postural awareness and include scapular setting
6 Weeks
Gradually discard sling
As pain allows progress to full passive range of movement
Add active assisted progressing to active exercises
Introduce anterior deltoid strengthening exercises as appropriate
Isometric strengthening of all groups and progress to isotonic, as the patient is able
Can begin hydrotherapy where available
Can encourage the patient to move through all ranges with attention to self-stretching at end of range
Proprioceptive exercises and core stability work as required
Return to Functional Activities : (earliest recommendations)
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Driving 8 weeks (dependent on ease of movement and safety)
-
Swimming
-
Golf - 3 months
-
Light lifting can begin at 8 weeks. Avoid lifting heavy items for 6 months
-
Return to work - The patient should be guided by the surgeon.
N.B. The protocol for a shoulder replacement following a fracture is less aggressive than that of the Copeland Shoulder Replacement due to the bony injury and the need to protect the healing of the tuberosities.
Active movement is delayed to allow for bony union. Progression will be slower. Use pain and the patient's ability as your guide.
Please check with the relevant Consultant for individual variances to the protocol.
Verso - Reversed Total Shoulder Replacement
The Reverse Geometry Total Shoulder Replacement is designed for use in shoulders that have
a severe arthritis with a deficient rotator cuff (Rotator cuff arthropathy) or following complex
fractures with a deficient rotator cuff. This has caused pain and loss of active movement in
the arm.
The Verso prosthesis changes the orientation of the shoulder such that the normal socket
(glenoid) is replaced with an artificial ball, and the normal ball (humeral head) is replaced with
an implant that has a socket into which the ball rests.
The design changes the mechanics of the shoulder allowing pain relief and an improvement
in function and stability, particularly when using the arm in front and above shoulder level.
The operation is carried out under general anaesthetic and a nerve block, with the incision
being approximately three inches long on the front-side of the shoulder.
The arm is then placed in a sling with body belt.
Post Op
Day 1
Mastersling with body belt fitted in theatre
Cryo-cuff administered to reduce inflammation
Finger, wrist and radio-ulnar mobilising exercises
Active elbow flexion and extension started
Shoulder Girdle exercises and postural awareness
Day 2 ・5 (Discharge)
Body belt removed ・stay in sling
Axillary hygiene taught
Continue Cryo-cuff
Maintain exercises as above
Start GENTLE pendular swinging in forward leaning
Week 1 ・3
Start PASSIVE shoulder exercises ・Flexion/extension, Int/external rotation
(Do NOT force any movement) as instructed by your physiotherapist
Use analgesia as required, regularly, to allow maximum comfort during all
arm exercises and daily functions
Start Scapular setting exercises
Continue pendular exercises as above
Continue shoulder, elbow, wrist and hand exercises
Stay in sling except when exercising
Week 3 ・6 - Clinic Review
Start formal physiotherapy ・to increase range of motion.
Avoid forcing any movement. Do not push the shoulder into painful positions.
Start the Deltoid Regime ・see A4 booklet given to you in hospital,
under the instruction of your physiotherapist
Wean from sling as comfortable but always wear sling when outdoors.
Continue to stretch regularly throughout the day, where possible in lying,
maintaining good range of movement in the elbow, wrist and hand.
Slowly increase the daily use of the arm, but avoid painful activities
Week 6 ・12
Continue with physiotherapy, as instructed
Increase the Deltoid regime as described in the hospital booklet
Stop wearing the sling
Continue stretches maximising range of motion in all directions
Use the arm and hand as fully and normally as possible, in comfortable
positions.
Week 12 - Clinic Review
Continue stretches maximising range of motion in all directions
Continue with physiotherapy, as instructed
Increase the Deltoid regime as described in the hospital booklet
Use the arm and hand as fully and normally as possible, in comfortable positions.
Arthroscopic / Open Anterior Stabilisation
