Rotator Cuff Physical Therapy, Rehabilitation and Return to Sport

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

• ▪

  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 ( ).

• ▪

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

• ▪

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

• ▪

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

• ▪

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

• ▪

  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.