1. 16/12/2012
Lennard
Funk
Shoulder
Surgeon,
Wrigh3ngton
Hospital
Professor,
Salford
University
Accelerated
R
ehab
a3onale
1
2. 16/12/2012
So
why
need
Physio?
ACJ
Arthri3s:
Surgery
&
Physio
• Shoulder
comprises:
5
ar3cula3ons
and
numerous
muscles,
tendons
and
ligaments.
• Injury
to
any
one
of
these
effects
the
others.
This
is
where
Physiotherapy
comes
in.
Shoulder
Surgery
Outcomes
Patient
Surgeon
Therapist
2
5. 16/12/2012
Open
Subacromial
Decomp.
/
ACJ
Excision
REHAB:
• Protect
reabached
Deltoid
&
Deltotrapezial
fascia:
– Immobilise
for
at
least
3
weeks.
– Avoid
Deltoid
resistance
exercises
for
at
least
6
weeks.
• Surgical
wound
with
sutures
removed
at
two
weeks
• Haematoma
care
&
bruising
ASD
/
ACJ
Excision
Scope Shaver
ASD / ACJ Excision
REHAB:
• No
detached
muscles
to
protect
• Commence
ac3ve
movement
and
discard
sling
as
soon
as
possible
–
day
1
or
2
post-‐op.
• No
sutures
/
wound
complica3ons
5
6. 16/12/2012
Sod
Tissue
Repairs
• Rotator
Cuff
• Labral
/
Stabilisa3on
/
SLAP
• Pec
Major
• Tendon
Transfers
Goals
• Protect
the
integrity
of
the
rotator
cuff
repair
• Minimize
postopera3ve
pain
and
inflammafon
• Restore
passive
range
of
mo3on
• Restore
strength
and
dynamic
stability
of
the
shoulder
• Restore
ac3ve
range
of
mo3on
• Return
to
func3onal/spor3ng
ac3vi3es
Tendon
Healing
• Tendon
–
bone
" Affected
by:
healing:
" Tissue
&
muscle
– 50%
at
3
weeks
quality
– 90%
at
6
weeks
" Quality
of
repair
" Smoking
" NSAIDs
" Loading
condi3ons
6
7. 16/12/2012
Factors
affec3ng
rehab
• Tissue
integrity
• Size
of
repair
• Loca3on
of
tear
• Tension
of
repair
• Tendon
to
bone
healing
• Pain
effects
of
immobilisa3on
Tendon
loading
Mehta. Clin J Sports Med. 2003
• Immobilisa0on:
Exercise:
• Decr.
Tendon
weight
Incr.
Growth
Factors
• Decr.
S3ffness
&
Incr.
tensile
strength
tensile
strength
Incr.
cross-‐sec3onal
area
• Irregular
collagen
Realign
collagen
fibres
Type
1
>
Type
3
collagen
• Type
3
>
Type
1
collagen
• Degenera3ve
changes
7
9. 16/12/2012
Rotator
Cuff
Repair
Rotator
Cuff
Tears
• Open
• Open
Surgery
• Arthroscopic
Single
vs
Double
Row
9
10. 16/12/2012
Releases
Important
to
perform
complete
releases
of:
• all
adhesions
• Coracoacromial
Lig
• Coracohumeral
Lig
• Posterior
bursa
• Anterior
bursa
Rotator
Cuff
Repair
Rehab
REHAB:
• Protect
Repair
un3l
healed
• Early
Mobilisa3on
• Depends
on
size
of
tear
and
cuff
quality.
Be
Aware:
• Elderly
• Smoker
• Faby
Infiltra3on
of
Muscle
• Quality
of
Tendon
at
Surgery
• Size
of
Tear
10
14. 16/12/2012
Hill-‐Sachs
-‐
Remplissage
Latarjet
Procedure
• Glenoid
Bone
Loss
Safe
Zone
14
15. 16/12/2012
Phase
&
Sport
Specific
Rehab
" Phase 1: (Level 1 Exercises)
" Core stability & Scapula control
" Proprioceptive exercises (minimal weightbearing below 90 degrees)
" Active assisted ROM as comfortable (in 'safe zone' )
" Do not force or stretch
" No combined abduction & external rotation
" Phase 2: (Level 2 Exercises)
" Progress active assisted to active ROM as comfortable
" Phase 3: (Level 3+ Exercises)
" Regain scapula & glenohumeral stability working for shoulder joint control rather than range
" Gradually Strengthen
" Plyometrics and pertubation training
Rehab
• Based
on
maintaining
safe
range
of
movement
in
the
first
phase
and
then
gradually
building
strength
in
the
middle
to
the
last
phase.
• Pre-‐op:
– ROM
Exercises
– Maximise
shoulder
strength
of
deltoid,
intact
cuff
muscles
and
scapula
stabilisers.
<
3
weeks
-‐
Level
1
• Passive
/
Ac3ve
Assisted
ROM
in
all
direc3ons
as
tolerated
• Shoulder
girdle
exercises
&
Scapula
sefng
exercises
• Closed
chain
exercise
15
16. 16/12/2012
Level
1
<
20%
EMG
3-‐6wks
-‐
Level
2-‐3
• Wean
off
Sling
• Do
not
force
or
stretch
• Isometric
exercises
in
neutral
as
pain
allows
–
up
to
50%
maximum
voluntary
contrac3on
• Open
Chain
Exercises
as
tolerated
Level
2
20-‐40%
EMG
16
17. 16/12/2012
6+
weeks
=
Level
3+
• Progress
to
full
ac3ve
and
resistance
exercises
in
all
ranges
6+
weeks
Shoulder
classes
17
21. 16/12/2012
Coracoclavicular
Ligaments
Harris et. al. Am J Sports Med. 2000
• Strength
–
500N
(+/-‐
134)
• S3ffness
–
103N/mm
(+/-‐
30)
• Uniaxial
Tension
25mm/min
Harris
et
al.
AJSM
2000
“None
of
the
reconstruc3on
techniques
analyzed
in
the
present
study
were
able
to
restore
the
normal
mechanical
func3on
of
the
intact
coracoclavicular
ligament
complex”
Func3onal
Anatomy
21
22. 16/12/2012
CC
Lig
Posi3ons
CA
Ligament
Transfer
(Weaver-‐Dunn)
• 20%
loss
of
reduc3on
• 20%
of
CC
Lig
strength
• Immobilisa3on
1. Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU. Surgical treatment of complete acromioclavicular
dislocations. Am J Sports Med 1995;23:324-31
2. Deshmukh AV, Wilson DR, Zilberfarb JL, Perlmutter GS. Stability of acromioclavicular joint reconstruction: biomechanical
testing of various surgical techniques in a cadaveric model. Am J Sports Med 2004;32:1492-8.
3. Grutter PW, Petersen SA. Anatomical acromioclavicular ligament reconstruction: a biomechanical comparison of
reconstructive techniques of the acromioclavicular joint. Am J Sports Med 2005;33:1723-8.
CC
Lig
Reconstruc3on
Hamstrings
Donor
site
morbidity
Allograd
Access;
cost;
Prion
risk
Synthe3cs
Non-‐biological
3ssue
22
23. 16/12/2012
LARS
Ligament
(Corin)
• Braided
Polyester
• 1500N
tensile
strength
(30
LAC)
• No
reduc3on
in
mechanical
resilience
ader
over
10
million
wear
cycles
loaded
in
torsion,
trac3on
and
flexion
• Vascularisa3on
&
Fibrous
ingrowth
-‐
Collagen
Type
1
Incision
Shoulderdoc.co.uk
Nofngham
Approach
Shoulderdoc.co.uk
23
25. 16/12/2012
Closure
• Repair
the
Superior
AC
Ligaments
• Repair
the
Delto-‐Trapezial
Fascia
3
weeks
post-‐op
Shoulder
Replacement
25
26. 16/12/2012
Shoulder
Replacement
-‐
Points
• Subscapularis
divided
Shoulder
Replacement
Post-‐Op
• Sling
for
TWO
DAYS
• SIX
WEEKS
Avoid:
–
Passive
External
Rota3on
– Ac3ve
Internal
Rota3on
Shoulder
Replacement
–
Capsule
• Capsule
is
released
at
surgery
circumferen3ally
to
improve
ROM
post-‐
op
• -‐>
Early
ROM
to
prevent
S3ffness.
26
27. 16/12/2012
Summary
• Understand
the
Procedure
• Muscles
cut/detached
-‐
protect
• Safe
ROM
for
repair
• Avoid
Stretching
and
Forcing
• Communicate
with
Surgeon
doc.co.uk
shoulder
lenfunk@
27
