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Rotator Cuff Arthropathy. Andre Le Leu Physiotherapy Clinical Specialist Shoulder and Elbow Unit Stanmore, UK. Contents. Anatomy Pathology Sub-acromial Impingement Syndrome Clinical Assessment Treatment methodology. Anatomy. Anatomy. Acromium. Rotator interval. Supraspinatus.

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Rotator Cuff Arthropathy


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rotator cuff arthropathy

Rotator Cuff Arthropathy

Andre Le Leu

Physiotherapy Clinical Specialist

Shoulder and Elbow Unit

Stanmore, UK

contents
Contents
  • Anatomy
  • Pathology
  • Sub-acromial Impingement Syndrome
  • Clinical Assessment
  • Treatment methodology
anatomy1
Anatomy

Acromium

Rotator interval

Supraspinatus

Posterior/

Superior

Zone

Infraspinatus

Corocoid

Anterior

Zone

Teres minor

Subscapularis

Glenoid

NB: Subacromial Bursa not illustrated here but a critical element

biomechanical considerations
Biomechanical Considerations

Deltoid

Suprasp.

Infraspin

Subscap

Teres Minor

cable theory
Cable Theory

subscap

Teres Minor

Posterior Pillar

Anterior Pillar

LHBT

Supra/infra sp.

rotator cuff tendonopathy
Rotator Cuff Tendonopathy

40 yrs

50 yrs

60 yrs

80 yrs +

Intra-substance tears

Plasma enrichment

Surgical debridement

PHYSIOTHERAPY +++

Salvage ops

Tendon transfers

Constrained TSR

FUNCTIONAL REHAB

‘Repetitive strain’ overuse

Biomechanical impingement

Angiogenesis

Up regulation of fibroblast activity

PHYSIOTHERAPY +++++++

Rotator cuff tears

Rehab

Surgery

GENTLE PHYSIOTHERAPY

rotator cuff examination
Rotator Cuff Examination
  • No test is absolute and definitive
  • Tests are merely a provocation symptoms rather than a confirmation of diagnosis (Lewis, 2008)
  • 90% of diagnoses are made from the patient history (Malone, 2005)
examination
Examination
  • Look….

Postural alignment

Bony landmarks

Muscle bulk/atrophy

General (scars, limb perfusion etc)

  • Feel….

Palpation (joint lines, muscle belly, ligaments/bursa)

  • Move….

Active movement, passive movement, resistance

DO NOT FORGET NEUROVASULAR COMPONENTS / CLEARING TESTS

special tests
Special Tests
  • Supraspinatus
    • Jobes Test 90 degrees scaption

Internal rotation (thumb down)

Without resistance then with resistance

Pain and or weakness

Modification to start in thumbs up and run resistance testing through range to include rotator interval component.

  • Initiation of Abduction testing
          • Arm by the patients side
          • Palpate the Humeral Head
          • Assess resisted abduction
          • Weakness, pain, superior translation of humeral head
          • are all indicative of a positive test
subscapularis
Subscapularis
  • Gerber’s Lag sign

As above but the therapist positions the hand ways from the spine and the patient must hold this position. (80% sensitivity for small tears)

  • Gerber’s lift off test

Hand behind the back at 90 degrees elbow flexion

The patient must keep the arm away from the spine

The Therapist can add resistance

(90% sensitivity for weakness or pain)

  • LaFosse belly press

Hand rests on belly with wrist at neutral away from the forearm

Held away from the body.

The patient pulls the entire arm into the stomach (watch for drop of elbow or wrist), can also add therapist resistance to the outside of the elbow

Good for patients with restrictions to movement

Recruitment of P.major in 25% clouds the examination

infraspinatus and teres minor
Infraspinatus and Teres Minor
  • Resisted testing

1. External rot lag sign (ERLS) with arm at waist the therapist positions arm in full external rotation and the lets go while the patients attempts to hold this position. You can then add therapist resistance and required looking for pain/weakness.

2. Patient Holds arms in 60 degrees scaption with elbows at 90 degrees. Patient must resist internal rotation movement against the therapist.

Pain and or weakness can be indicative of posterior cuff insufficency.

infraspinatus and teres minor1
Infraspinatus and Teres Minor
  • Patte’s Test

90 degrees of abduction and external rotation, the patient must hold against resistance.

Watch for correct scapulo-thoracic alignment

Can test eccentric control element

  • Hornblowers Sign

Arm held in 90 degrees scaption with hand in front of the mouth (supination). Patient must move the arm out into external rotation against gravity, however the therapist can also look to add resistance.

  • Hornblowers lag sign

Arm is positioned at 90 degrees in scaption with full external rotation by the therapist. The Patient must the hold this position once the therapist lets the arm go. A positive drop sign is indicative of a massive posterior cuff tear.

biceps tendon
Biceps tendon
  • Check for Popeye sign (rupture of LBHT)
  • Speeds test

Patient holds straight arm in supination at 90 degrees flexion and tries to elevate the arm against the therapists resistance. Pain indicative of provocation.

90% Sensitivity and 15 % specificity (Malone 2005)

  • LaFosse AERS test(abduction, ext rot, supination)

Arm is held at 90 degrees abduction and externally rotated with elbow at 90 degrees in pronation.

The Therapist provides resistance as the patient supinates the arm

Pain is indication of possible biceps irritation or SLAP tear

  • Yergason’s test
        • arm by side and elbow at 90 degrees, the therapist holds the patients hand and resists the patient moving into supination while palpating the LHBT.
        • Look for pain and or subluxation of tendon from bicepital groove
shoulder impingement syndrome
Shoulder Impingement Syndrome
  • Extrinsic Primary Acromial shape
  • ACJ pathology
  • Hypertrophied CA lig
  • Chronic Synovitis of Bursa
  • Secondary Instability (micro and gross)
  • Posterior capsule tightness
                  • Neurogenic
  • S/T dysrythmia
  • Intrinsic Hypovascularity
  • Age related degenerative changes
  • Overuse
  • Cuff weakness/fatigue/cuff rupture
impingement tests
Impingement Tests
  • Neer’s Test
        • Therapist stands behind the patient and stabilizes the scapular. The holds the arm in ‘thumbs down’ in full elbow extension.
        • The maneuver is to the elevate the arm into f.flexion
        • Provocation of pain (80% specificity for bursa and cuff problems Malone et al)
  • Hawkins (Kennedy) Test
        • Therapist holds he arm in the plane of the scapular with the elbow at 90 degrees.
        • The hand is put into a thumbs down position and then the arm is medially rotated, a positive test provokes pain/restriction of movement (90% sensitivity, Malone et al)
acromioclavicular joint
Acromioclavicular joint
  • Pain on palpation
  • Pain at end range abduction, hand behind back
  • Scarf test
          • Pain provocation with horizontal adduction
          • NB restriction of movement may be due to posterior capsular stiffness esp. if scapular is held in retraction
innervation
Innervation
  • Suprascapular nerve
  • Nerve to Subscapularis
  • Axillary or Circumflex nerve
  • Lateral Pectoral Nerve
  • Autonomic Nervous System (LBHT)
practical session
Practical Session
  • Basic Assessment
  • Provocation Testing
  • Where to Start Rehab?
indications for surgery
Indications for surgery
  • Pain
  • Loss of function and ROM
  • Quality of life
  • Failed conservative management
  • Age related considerations
pathology

Pathology

AVN

Tumours

Infection

types of shoulder prosthesis
Types of Shoulder Prosthesis
  • Fully constrained = For severe arthritis of the shoulder and destruction of the rotator cuff. Basically a salvage procedure.
  • Semi constrained = To prevent superior subluxation of the humeral prosthesis when the patient has joint arthritis and rotator cuff insufficiency.
  • Un Constrained =Joint arthritis with good rotator cuff function.
  • Surface replacement= one articular surface involved
cemented or uncemented
Cemented

Reduced pain reported

Increased mobility

Senior population

Less physically demanding lifestyle

Uncemented

Avoid loosening of parts

Scope for revision in younger person

Active lifestyle

Extended recovery period

Cemented or Uncemented?
rnoh philosophy
RNOH Philosophy
  • Bone Stock & Rotator Cuff
    • Good BS / good RC = unconstrained TSR
    • Good BS / poor RC = Constrained
    • Poor BS / good RC = CAD-CAM stem
    • Poor BS / poor RC = CAD-CAM glenoid/stem
unconstrained
Unconstrained

Sulzar TSR – with glenoid liner (cemented)

Glenoid screw and Biomet Humeral Component

Modular (no glenoid liner)

Cemented or uncemented

constrained
Constrained

Reverse Delta-3

constrained1
Constrained

Reverse Fixed Fulcrum (Bayley-Walker)

rnoh rehabilitation guidelines

RNOH Rehabilitation guidelines

Weak and smooth shoulder

Stiff shoulder

post operation immobilisation
Post operation immobilisation

Abduction pillow

polysling

rehab guidelines all of this will vary according to the individual
Rehab GuidelinesAll of this will vary according to the individual

Phase 1 – Initial Rehab

Optimise tissue healing (time specified)

Pain control “SMOOTH AND WEAK”

Use of sling

No ER>neutral/20 degrees

A-A/Passive elevation<90 degrees

No active use of UL or strengthening

No HBB or cross body

Education

Milestones for next stage

Achieved time specific goals

For X-rays to show osseo-integration

Allowed ROM achieved

Reduced pain

Adequate scapula control

early phase day 1 6 52 exercise
Early phase day 1 -6/52 exercise

Active assisted GHJ FF 90

ISOMETRIC ER IN NEUTRAL

Carer performing the exercise

ISOMETRIC IR IN NEUTRAL

early phase day 1 6 52 exercise1
Early phase day 1 -6/52 exercise

Start position with shoulder supported

Carer performing the exercise

End position of exercise

Active assisted GHJ ER to neutral start…

slide39

Phase 2 – Early Recovery (approx 6 weeks – 4 months)

Decrease sling use

Start light activity at waist level

Increase ROM

Optimise normal movement patterns

No exercises that increase pain

No active anti-gravity work until RC rehabilitated

Deltoid Programme for Constrained TSR

Milestones for next stage

No sling

Minimal pain

Passive ROM: elevation>90 and ER>30

RC stabilises within available ROM

Functional Triangle

slide40

Phase 3 – Late Recovery (approx 5 months – 12 months)

Increase strength and endurance to functional level required

No exercises that increase pain

No heavy lifting above shoulder level

Milestones for Discharge

Reduced pain from pre-op status

Achieved functional goals

Expected outcomes

Unconstrained – Light to moderate use at waist, shoulder and above shoulder level

Constrained – Light use at waist level and

towards shoulder height if possible

May take 12-24 months to achieve

rehabilitation guidelines
Rehabilitation Guidelines
  • www.rnoh.nhs.uk
  • Follow link to CLINICAL SERVICES
  • Click on Physiotherapy
  • Click on SHOULDER AND ELBOW UNIT
  • Select Guideline for exercise information