Advances in shoulder surgery and rehabilitation - Len Funk 2012

Arthroscopic Shoulder
Surgery has Progressed

... Has the Rehab?
Lennard Funk

Sunday, 18 March 2012

Full Time / Part Time


YES
and

NO

Quiz ...


Question 1

The exercises that best protect a surgical
repair are:
a. Open kinetic chain
b. Closed kinetic chain
c. Concentric
d. Full range of motion


Question 2
Exercise progression should be based on:
a. Procedure performed
b. Range of motion
c. Control of scapular position
d. Acquisition of function


Question 3
Immobilisation after shoulder surgery
repair leads to:
a. More stiffness
b. Less revisions
c. Earlier recovery of Strength
d. Better Proprioception


Question 4
Tendon healing:
a. Is improved with movement
b. Takes less than 3 months
c. Is strain related
d. Is improved by steroid injections


Shoulder Surgery Progress
Hippocrates
(460-377 BC)

Codman
(1937)
Watanabe

Neer
1990s+
Snyder,
Andrews,
Burkhart,
Gerber,
Copeland etc.


Arthroscopy
The needle with an eye

“The everyday
miracle, that keeps
getting better”


Same Surgery – Smaller Access


Faster Recovery


A systematic review of rehabilitation
protocols following arthroscopic repair
of rotator cuff tears
Donaldson, Wright & Funk. SECEC 2011

“There was insufﬁcient evidence in any
of the papers for the protocols
or exercises advocated in the
rehabilitation programs.”


Rehabilitation
The surgeon’s view


Post-operative Care


The effects of
Immobilisation


Fracture Healing


Too much movement


Controlled Motion

Rigid Fixation Micro-motion
(immobilised) (closed chain)


Soft Tissues

• Tendon
• Ligaments
• Labrum


Tendon Collagen


Tendon Failure

1.'Primary' or 'toe'
region.
2.'Secondary' or 'linear'
region.= Elastic
Region.
3. Yield point.
4. The ultimate stress/
strength
5. Sequential failure
6. Alternative failure


Tendon Healing


Tissue differentiation
with Healing
Pendergrast. K Biomech. 1997

1year


Immobilisation & Exercise


Strain Studies

Talwalker, Evans, Trail


‘Fracture’ Healing is like sex:

• It’s natural
• Needs two parts Alan Graham Apley
(1914-1996)

• ... and a bit of movement


Standard
Shoulder Practice Leftley & Funk, 2006

Shoulder Surgeons Shoulder Therapists
• Active & Passive ROM in
• Immobilisation 3-6 weeks safe zone, week 1

• Resistance training 6 weeks+ • Controlled resistance in
safe zone week 2
• Sport speciﬁc training after
12 weeks • Resistance work end of
range, weeks 6-8
• Return to Sport 6-8 months
• Return to Rugby 12 wks


Can you Protect and Rehab?
• Tendon Healing
• EMG Studies
• Kinetic Chains
• Clinical
• Stiffness
• Results


Tendon Loading
Immobilisation: Exercise:
• Decr. Tendon weight !Incr. Growth Factors
!Incr. tensile strength
• Decr. Stiffness & !Incr. cross-sectional
tensile strength
area
• Irregular collagen !Realign collagen
ﬁbres
!Type 1 > Type 3 collagen
• Type 3 > Type 1
collagen
Mechanical Adaptation
• Degenerative
changes Mehta. Clin J Sports Med. 2003


Muscles - EMG Studies
Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T.
AJSM, 2008.


Kinetic Chains
• Open Chain:
• Terminal link in the chain is not loaded and is
freely mobile
• Muscle activation is usually proximal to distal
• Closed Chain:
• Terminal link meets enough resistance to
prohibit or restrain its free motion
• Extremity muscle activation is sequential
from distal to proximal


Closed Chain:


Open Chain:


Closed Chains
• Relatively small joint movements
• Low joint accelerations
• Large resistance forces
• Joint compression
• Decreased joint shear,translation, distraction
• Stimulation of joint proprioception
• Enhanced dynamic stabilisation through
muscle co-activation


Closed Chains
Kibler WB, Livingston B. AAOS. 2001.
Veeger HEJ, van der Helm FCT. Journal of Biomechanics. 2007

Anatomical:
• Anterior strut:
• S- C joint, clavicle, A- C joint
• Bony attachment to axial skeleton
• Posterior strut:
• Scapula
• Muscular attachment to axial skeleton


Closed Chain Disrupted
• Anterior
• Clavicle fracture- shortening, angulation, malrotation
• AC joint separation
• Excessive distal clavicle resection
• Posterior- Scapular dyskinesis
• Muscular alteration (inhibition, fatigue, patterning)
• Inﬂexibility (pec minor, biceps, GIRD)
• Scapular muscle detachment
• Nerve injury/palsy


Principles of Rehab
Correct the mechanical ﬂaws

Restore the integrity of
the kinetic chain

Reestablish normal function


Restoration of the Kinetic Chains
1.Pre operative
2. Early Post-op
1. Restore motion and stability in non-
injured areas 1. Even while shoulder is protected
1. Anterior coracoid muscles
2. Restore scapular posture, position
2. GIRD
3. Allow early safe scapular motion
3. Scapular retraction
2. Early start on post operative 4. Minimal strain on shoulder repair
rehabilitation
3. Instruction in post operative exercises
3. Later Rehab:

1. Allow maximal concavity/compression
1. Kibler & Livingston.
AAOS. 2001. 2. Allow maximal rotator cuff activation & strength
2. Veeger et al.
Journal of Biomech. 2007
3. Proximal base for open chain motions of arm


Shoulder Proprioception
• Rapidly lost after injury
• Reduced with immobilisation
• Improved with closed-chain rehab.

•Smith & Brunolli, 1989
•Lephart, 1994, 1997
•Zuckerman, 1996
• Edmonds, 2003


Immobilisation

• No such thing!
!

• High Cuff activity during all light
resisted backward pulling motions
(25.2% to 32.1% MVC) [Padgett, 2004]

• Low Cuff activity with closed-chain
scapulothoracic exercises (<20% MVC)
[Smith et al. Arch Phys Med Rehab.2006]


Recovery of Strength
Hortobágyi et al. J Physiology. 2004


Stiffness
• No difference in long-term
• Monga & Funk. SAE. 2011; Parsons et al. JSES. 2010

Patients with Residual stiffness vs Time

300

250
200
Number

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12
Time


Clinical Literature
• Strict immobilisation resulted in functional instability with rotator cuff
inhibition, muscular atrophy and poor neuromuscular control
(Wilk et al 1993)

• Moderate stresses should be placed on the suture line before the end of 3
weeks to inﬂuence the scar tissue outcome (Blackburn & Guido 2000)

• Increased stress within a certain limit enhances ligament healing and
improves joint function (Kim et al 2003)

• Closed chain exercises are an integral part of accelerated rehab
programmes, they should be started early and used throughout the
rehab process (Kibler 2000)

• Accelerated rehabilitation promotes functional recovery and reduces
postoperative pain, which allows patients an early return to desired
activities (Kim et al 2003)


What we know:
• Early ‘safe’ mobilisation is GOOD for:
• Strength
• Tendon healing
• Kinetic Chain
• Proprioception


We also know:

• No difference to: Stiffness


We don’t know:

• Effect of immobilisation / mobilisation
on retear rates


Considerations
Kathleen Tatlow

Reduce
Pain

Timing ROM
Post-op Return to
considerations Normal
ADL

Muscle Muscle
Flexibility power


Rehab Guidance

Medical Multimedia Group


Exercise Booklet


Protocol
• Day 1 – 3 Weeks
• 0-20% EMG Exercises
• Low activity

• 3 – 6 Weeks
• 21-40% EMG Exercises
• Minimal activity

• 6 Weeks +
• 40% + EMG Exercises Tim Uhl, 2005
Leftley & Funk, 2006

• Moderate to high activity


0 – 3 weeks
0 – 20% EMG


3 – 6 weeks
21 – 40% EMG


Week 6 +
40% + EMG


Arthroscopic Shoulder
Surgery has Progressed

... Has the Rehab?


YES
• Tendon Healing
• Mechanical Adaptation
• Kinetic Chains
• Proprioception
• Early Mobilisation


NO
• Application
• Fear
• Tradition
• Ignorance


Question 3
Immobilisation after shoulder surgery
repair:
a. More stiffness [Monga & Funk. SAE. 2011]
b. Less revisions [Kralinger. AJSM. 2002]
c. Earlier recovery of Strength
d. Better Proprioception


derdoc .co.uk
lenfunk @shoul


Advances in shoulder surgery and rehabilitation - Len Funk 2012

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Advances in shoulder surgery and rehabilitation - Len Funk 2012