Post Op Shoulder Flashcards by Ryan Angeles

General goals for post-op rehab

Promote healing/protect repair
Restore ROM (PROM >AROM)
Restore strength
Restore function

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When is subacromial decompression indicated?

During unresolved impingement or if imaging deems necessary -type III

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Failed conservative treatment of impingement defined by Cohen

No improvement with 3 months of a comprehensive rehab program

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Important thing to consider when it comes to protocol timelines

They are variable depending on the extent of surgery and what needed to be repaired (i.e. was there also a rotator cuff tear or labral tear)

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First phase of the protocol

Passive range of motion phase- typically 2-4 weeks, progressing to active assist and active ROM

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Second phase of the protocol

Strengthening- typically starts post-operative week 5 or 6, but very important to check with surgeon to determine course (when in doubt, utilize standard protocol timelines provided)

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Subacromial decompression is also known as

Distal clavicle excision

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Rotator cuff treatment progression

Non-operative management- success is dependent on status of remaining rotator cuff

Decompression without repair

Repair

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When is open repair used?

Used for large, massive tears where tissue integrity may be poor

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Open repair advantages

Greater exposure to surgical area and good post-operative outcomes

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Characteristics of open repair

Involves removal and reattachment of anterior deltoid and may require post-operative rehab considerations to protect the deltoid

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Open repair disadvantages

May be marked by longer recovery and increased post-operative pain and decreased anterior deltoid function

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Mini open characteristics

Splits deltoid vs detach/reattach of open procedure

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Outcomes of mini open repair

Similar outcomes to open repair

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When is arthroscopic surgery used?

For smaller tears with good tissue integrity

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Benefits of arthroscopic surgery

Less risk of infection, stiffness, and deltoid compromise

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Types of arthroscopic surgery

Double row vs single row

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Passive range of motion phase for small to medium tear

Greater than or equal to 4 weeks (could be as much as 6-8 weeks with more conservative surgeons)

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Active range of motion phase for small to medium tears

~8 weeks(could be as much as 6-8 weeks with more conservative surgeon)

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Strengthening phase for small to medium tear

~12 weeks

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Passive range of motion phase for massive tears

Greater than or equal to 6 weeks (could be as much as 8 weeks with more conservative surgeons)

Active range of motion phase for massive tears

~12 weeks (could be as much as 8 weeks with more conservative surgeons

Strengthening phase for massive tears

~18 weeks

When was accelerated rehab popular?

Early 200s when mini open and arthroscopic procedures were popular

What was the thinking behind accelerated rehab?

The procedure was less invasive so accelerated protocol could be used

When was decelerated rehab popular?

In the mid to late 200s when surgeons started to find cuff failures and shut everything down and aggressive PT was blamed

General rehab guidelines for RCR

Protect the repair Passive ROM early Early muscle training Strengthening progression

Important info for PROM for general rehab guidelines for RCR

Rotational motion 1st at 30-45 degrees of abduction (in scapular plane) working up to 90 deg of abduction, also layer in arm at side

Important info for early muscle training for general rehab guidelines for RCR

Initially contractile palpation: rhythmic dynamic stabilization and/or isometrics

Important info for strengthening progression for general rehab guidelines for RCR

Once strengthening begins, progress no more than 1 lb per week

Success for RCR

Balance of stress and compression for promoting healing but not inhibiting healing process

Reasons for failure for RCR

Patient adherence Rehab Surgical causes

How can rehab contribute to failure for RCR

Over aggressive progression- strengthening exercises should remain low load throughout, strength can always be regained in time Early PROM/AAROM is critical to avoid contracture or motion loss

How can surgery contribute to failure for RCR

Inadequate technique or implant Didnt restore anatomical footprint Double row vs. single row technique

Indications for labral repairs

Failure of conservative management Slap lesion with significant RCT (>50%) Debridement of types 1 and 2 Repair of types 3 and 4

Rehab considerations for labral repairs

Type of repair Early limitation of ER to prevent "peel back" mechanism Avoid resistive biceps activity (flexion/supination) until at least 8 weeks post-op Avoid 90/90 position for 6 weeks post anterior labral repair Avoid horiz add for 6 weeks (SLAP doesnt matter) for posterior labral repair

Total shoulder arthroplasty (TSA) indications

Shoulder joint pain from destructive arthritis secondary to OA, RA, or traumatic arthritis Avascular necrosis Severe loss of upper extremity strength Limitations of ADL function secondary to pain

Where is the incision in TSAs?

Between deltopectoral crease

Hemiarthroplasty may be done in TSAs if...

glenoid surface is adequate (controversial)

TSA may also include...

RCR

Detachment of the sabscapularis in TSA guidelines

Avoid active IR until at least 6 weeks | Limit PROM ER in early phases

TSA outcomes

95% have pain relief Near normal range, strength, function as possible Vulnerable in 90 deg abd + ER

What is a predictor of post-op ROM outcomes for TSA

Pre-op ROM

What should be known about goal expectations following TSA?

They are limited with cuff deficiencies or previous trauma injuries

RTSA indications

Complete RCT that cannot be repaired Previously unsuccessful TSA Severe shoulder functional limitations due to pain

Contraindications for RTSA

Impaired deltoid function Isolated supraspinatus tear Full ROM and good function despite massive RCT

RTSA outcomes

High rates of dislocation in anterior superior direction Will not regain full ROM but optimally will have less pain and "functional AROM" Need deltoid strengthening

After RTSA, shoulder is vulnerable in...

Extension, adduction, and internal rotation e.g. pushing up from chair in shoulder extension

How to avoid anterior superior direction dislocation after RTSA

Avoid reaching across chest for up to 6 weeks | Avoid reaching behind back for 10-12 weeks

Active elevation ROM following RTSA

Likely to reach 105-140 deg

Rotation ROM is dependent on what following RTSA?

Rotation ROM is dependent on pre-operative status of teres minor