Special Considerations. Gaunt B

Transcription

1 Gaunt B Figure 25. The V raise exercise. Figure 26. Dumbbell overhead press with hands starting in front of the shoulder. planar activities (Figures 16 and17). Plyometric chest passes, 2-hand overhead throws, 2-hand side throws, and 2-hand diagonal throws also were used first with a basketball and second with a weighted ball as part of the progression of multiplanar, high-speed, and power activities from POW 12 through POW 18. At POW 18, the patient received clearance to begin a more comprehensive modified weight-training progression (Chapter IV-4), including exercises with a gradual increase in stress to the anterior capsulolabral structures. Lateral bar pull-downs with the bar in front of the head (Figure 27), weighted shoulder shrugs, and partial-range push-ups in which the elbows were not Figure 27. Pull-downs in front of the head. allowed to pass behind the plane of the glenohumeral joint were initiated at this time. Full-range push-ups began 2 weeks later, and partial-range machine chest press and barbell press were begun at 5.5 postoperative months (POMs). During this time, the amount of weight was kept light by requiring the patient to perform sets of 15 to 25 repetitions with all exercises. At 6 POMs, full-range chest presses and deadlifting were allowed with gradually progressing weight. The patient was allowed to begin power cleans and dumbbell chest presses at POM 7. He was counseled to always avoid weight-training exercises that place a stretch on the anterior portion of the shoulder, such as dips, shoulder presses with a barbell behind the head, and full-range pectoralis flys. Regarding football-specific conditioning and training drills, the patient was allowed to begin jogging at POM 2. Sprinting and lower body agility drills began at POM 3. Activities requiring modest upper body weight bearing, such as bear crawls, began at POM 5. Individual football drills that impart high levels of stress to the shoulder, such as hitting a blocking sled, were begun at POM 6. The patient was fully released to participation at POM 7. Special Considerations In this section, I describe some situations that require varying amounts of modification to our standard rehabilitation guideline for arthroscopic plication with or without Bankart repair. 306 The Systematic Approach to Shoulder Rehabilitation

2 Arthroscopic Capsular Plication With or Without Bankart Repair Open Repair for Instability Open repair for instability has demonstrated very good long-term results with a low rate of recurrence. 36 Rehabilitation of patients after primary open repair for anterior or multidirectional instability is different from rehabilitation after arthroscopic repair in the early postoperative period but is essentially the same in the later stages of rehabilitation. Differences in early rehabilitation are needed to protect the subscapularis and to minimize the loss of ROM, which can occur after these procedures. Revision open repair for instability requires different modifications and is addressed later in the Special Considerations section. Open repair of a Bankart lesion or open anterior or inferior capsular shift of the glenohumeral ligaments requires either splitting or detaching the subscapularis during the procedure to gain access to the capsulolabral complex. If the surgeon detaches the subscapularis, which is repaired anatomically at the end of the surgical procedure, it is an additional structure that requires protection for appropriate healing. No active or resistive IR, including isometrics, is appropriate during the first 6 POWs, and gentle measured strengthening is important for the next 3 to 4 weeks. The subscapularis also must be protected during ER PROM exercises during the first 6 weeks to avoid excessive stress to the healing suture line. Generally, the same staged ROM goals for ER that are shown in Table 1 are appropriate in this situation, but some physicians might limit the maximal ER to be obtained during phase 1 rehabilitation to a greater degree. Just as important is ensuring the patient relaxes to prevent muscle guarding of the subscapularis during ER PROM exercises. To avoid muscle guarding, the early passive ER exercises I prefer are seated passive ER with the assistance of the rehabilitation provider or family member (Figure 28) or the passive ER table walk-around (Figure 29). If the surgeon splits the subscapularis then sutures it closed instead of detaching the tendon, these modifications are used until the acute postoperative pain subsides. Likely due to the increased tissue dissection required with open repair for instability compared with arthroscopic repair, the staged ROM goals shown in Table 1 are often more difficult to achieve. Therefore, most surgeons start PROM within the first week after open repairs. A bigger emphasis on PROM usually is required during phase 1 and often during phase 2 and phase 3 rehabilitation. In addition, the rehabilitation provider must ensure the patient stretches frequently and must closely monitor PROM gains to ensure staged goals are met. With a rehabilitation emphasis on frequent gentle stretching to achieve staged PROM goals, long-term PROM loss has been shown to be very minimal in these procedures. 32,37,38 After POW 6, the AROM, strengthening, neuromuscular control, and dynamic stability progression for open repair to treat instability is not different from arthroscopic repair. Return-to-sport time also is similar. Figure 28. Assisted sitting passive external rotation. Figure 29. Passive external rotation walk-around exercise. The St. Francis Orthopaedic Institute & HPRC at St. Francis Rehabilitation Center 307

3 Gaunt B The Patient With Hyperlaxity The patient with generalized hyperlaxity who undergoes an arthroscopic repair for instability requires a different rehabilitation emphasis and modifications to the base rehabilitation guideline. Generally, the surgeon is more concerned about recurrent instability in these patients than in typical patients, so changes to rehabilitation are individualized but often are made to slow the ROM progression, promote healing, and place extra emphasis on dynamic stability. Patients with hyperlaxity typically present with atraumatic multidirectional instability and are managed with an arthroscopic capsular shift that addresses the instability in multiple areas of the capsule. Labral tears and subsequent repairs are uncommon in this patient population. At our center, the most important change made to phase 1 rehabilitation is strict adherence to not exceeding the staged ROM goals, especially ER. In addition, when a range of staged ROM is given in Table 1, the more conservative measure generally is used as the stopping point. Therefore, the ROM limit for passive ER that we use at POW 3 in the patient with hyperlaxity is typically 20. To promote the slower ROM progression, the physician might delay the initiation of glenohumeral PROM until POWs 2 to 6. During this time, the patient only performs elbow, wrist, hand, and scapula AROM. When ROM is initiated, the patient might have more available PROM than the ROM limit. If this occurs, then no PROM is given to the patient for a home exercise in that direction. Therefore, phase 1 rehabilitation often is quite limited. Because dynamic stability provides protection to the repair, patients with hyperlaxity often are allowed to initiate some low-level, dynamic-stability exercises during the latter half of phase 1 rehabilitation. Submaximal isometrics and protected ER and IR ROM exercises with an elastic band might be used. Often, these patients also present with significant scapula dyskinesia, so scapula interventions that do not provide stress through the glenohumeral joint, such as manual pectoralis minor stretching and active scapula positioning, also can be used. Whereas closed-chain activities are good dynamic-stability exercises, those that require any substantial weight bearing through the upper extremity are not advised during this stage of rehabilitation. During phase 2 rehabilitation, stretching and PROM exercises still are de-emphasized, and AROM, strengthening, and dynamic-control exercises are emphasized. Passive ROM and stretching are not used for patients with preoperative hyperlaxity unless their ROM is moderately behind staged ROM goals. We have found that small deficits in PROM can be corrected with active-assistive or active strengthening into the restricted ROM in the late stages of phase 2. Exercises included in the assistive-to-active elevation progression, such as those shown in Figure 30, often are used for this purpose. The standard AROM and strengthening progression is used with increased emphasis on improving active control of the upper extremity, generalized muscle tone, and proprioception. Less emphasis is placed on activities with moderate to high resistance, and a slower progression to strengthening in end ranges of abduction with ER is employed. Closed chain exercises, such as those shown in Figure 12, are important to improve dynamic stability; however, careful monitoring is required to ensure that the patient is strong enough to maintain the humeral head centered in the glenoid because most patients with hyperlaxity present with preoperative multidirectional instability. Differences in phase 3 are mainly changes to timing and aggressiveness of rehabilitation. Because patients with hyperlaxity are thought to have to rely on dynamic stability to maintain stability in the shoulder more than other patients, we typically use a slower and more judicious return to advanced rehabilitation activities, such as multiplanar, high-speed exercises, at our facility. A slower return to sport activities and activities that require heavy lifting often is used, as well. Figure 30. Supine forward elevation with an elastic band. 308 The Systematic Approach to Shoulder Rehabilitation

4 Arthroscopic Capsular Plication With or Without Bankart Repair Revision Repair for Instability Rehabilitating a patient after either arthroscopic or open revision repair to treat instability is another highly individualized situation. The speed of progression should be determined by the referring physician and depends on factors, such as the number of previous failed repairs, tissue quality, bone loss of the humeral head and glenoid, whether bone grafting was necessary, and other coexisting conditions. A slower rehabilitation program is warranted because the tissues already have shown the tendency to fail. Appropriate modifications might include one or more of the following: using limited-goals rehabilitation (Chapter III-18), placing PROM limits on ER or forward elevation during the first 6 to 12 weeks, delaying the initiation of PROM exercises up to 6 weeks, or delaying the start of strengthening for 2 to 6 weeks. Depending on the patient, return to advanced strengthening activities, such as high-speed multiplanar exercises that require end-range abduction with ER and return-to-sport activities, are delayed or might never be appropriate. The surgeon always determines these modifications. The rehabilitation provider plays a vital role in repeated patient education throughout the rehabilitation process so patients understand the importance of complying with this slower-paced rehabilitation program. The St. Francis Orthopaedic Institute & HPRC at St. Francis Rehabilitation Center 309

5 Repair for Posterior Instability Rehabilitation of either arthroscopic or open repair for posterior instability uses the same guiding rehabilitation principles and the same methods to manipulate stress to the surgical repair as anterior and multidirectional capsulolabral repair. However, the part of the capsule that requires protection is obviously different; therefore, whereas the timing of rehabilitation is the same, somewhat different interventions are needed. The posterior capsule is thinner and weaker than the anterior capsule, which is thickened by the glenohumeral ligament complex. Repairs for posterior instability, therefore, require more protection and gentle rehabilitation than other repairs for instability, especially during phase 1 and the early part of phase 2 rehabilitation. The motions that are most stressful to the posterior repair are horizontal adduction, functional IR, and IR in both adduction and abduction. Rehabilitation of these patients, especially during phase 1, varies widely based on surgeon preference and on the patient. Table 4 outlines general rehabilitation guidelines for arthroscopic or open repair for posterior instability. The initial timeframe and extent of immobilization varies widely in these patients, as described in Table 4. Gaining staged PROM overhead in the true plane of the scapula is important to prevent a posteriorly directed force on the posterior capsule. Passive ER with the upper extremity near the side usually is achieved fairly easily with gentle stretching during this time. The amount of IR allowed in the first 6 weeks is restricted. The amount of restriction varies by the surgeon and patient and will be determined by the surgeon, but it typically is between 0 and 30 of IR. Variable PROM and stretching generally is needed during phase 2 rehabilitation because full ROM in all planes, including IR, horizontal adduction, and functional IR, is not targeted before 12 POWs. Often, limited stretching is needed, but more regular stretching is required if a particular motion is moderately restricted. Discretion should be used when issuing direct posterior capsule stretches, such as cross-body adduction and/or the sleeper stretch, as part of a home program. The rehabilitation provider only should give them when a moderate restriction in motion is present and should monitor progress closely to ensure ROM is not gained too quickly. Active ROM and strengthening principles and interventions for patients with a repair for posterior instability are very similar to that with repair for anterior instability, but the amount of load to the posterior capsule needs to be controlled. This mainly is done by delaying exercises that require a moderate body weight or external load through the repaired extremity. For example, exercises in the quadruped position are not begun until at least POW 9 and then are advanced slowly. Return to exercises or sports that require large amounts of posteriorly directed force through the shoulder girdle, such as bench pressing, football, and wrestling, are highly variable depending on surgeon preference and the patient but usually are not allowed before POM 6. Rotator Cuff Repair Combined With Arthroscopic Capsulolabral Repairs Gaunt B The patient who has had a rotator cuff repair at the same time as a glenohumeral ligament plication with or without a Bankart repair is difficult to rehabilitate because the surgeon has performed extensive procedures involving both the passive and active restraints of the glenohumeral joint. This combined surgical procedure generally results in increased pain during the first 4 to 6 POWs and a more difficult time achieving ROM goals, especially PROM. Because 2 completely different operations are performed at once and each has its own specific rehabilitation guideline, 1 guideline must be chosen as the primary guideline for this type of patient. The rotator cuff repair guideline takes priority; however, the chosen rehabilitation variable influences this decision. For PROM, a ROM that is detrimental to any of the surgical procedures is not safe during rehabilitation. The staged ROM goals for both procedures are roughly the same. Early horizontal adduction excessively stresses a supraspinatus repair, and excessive passive ER, especially in increasing degrees of abduction, excessively stresses an anterior capsular plication or Bankart repair during phase 1 and early phase 2 rehabilitation. However, as mentioned, limited PROM is often a greater problem with these patients compared with excessive PROM beyond allowed limits. For AROM, the rotator cuff repair guideline always is used to ensure adequate protection of the cuff repair. 310 The Systematic Approach to Shoulder Rehabilitation

6 Arthroscopic Capsular Plication With or Without Bankart Repair The instability repair is not affected negatively by the AROM and strengthening activities in the rotator cuff repair guideline. Delaying the initiation of AROM and strengthening often is indicated if the patient is behind in achieving the PROM goals or if the level of pain or inflammation appears elevated. For advanced rehabilitation, a gradual increase in stress to all repaired structures is required. However, for almost all rehabilitation activities in phase 3, the rotator cuff repair needs the greatest protection. Therefore, the rotator cuff repair guideline is given priority at this time, and the rehabilitation provider keeps in mind that a gradual progression of activities should be accomplished in the throwing position to appropriately apply a gradual increase in load to a capsulolabral repair. Compared with patients who have had either a rotator cuff repair or a capsulolabral repair, these patients generally progress through all phases of rehabilitation much slower, and they typically need at least 6 to 8 weeks longer to complete rehabilitation. Arthroscopic Capsulolabral Repair Combined With Repair of a Superior Labrum Anterior-Posterior (SLAP) Lesion Rehabilitation guidelines for these 2 procedures are complimentary, so very few changes to the base rehabilitation program are needed when these 2 procedures are combined. Although performed for slightly different reasons, staged ROM goals, time to initiate AROM, strengthening, advanced rehabilitation activities, and return-to-sport timeframes are nearly identical. Where differences do exist, the more conservative guideline always should be used. I have found that the Figure 31. An anterior labroligamentous periosteal sleeve avulsion lesion shows displacement of the labrum and ligaments from their anatomic positions on the scapular neck. Figure 32. A humeral avulsion of glenohumeral ligament lesion. patient who has both procedures performed at the same time might have more pain in the early postoperative period and might have a harder time gaining PROM during all stages of rehabilitation. Therefore, a greater emphasis often is placed on PROM and stretching in these patients, avoiding end-range abduction with ER until POW 12 to protect both the SLAP repair and capsulolabral repair. I have found these patients also tend to progress 2 to 6 weeks slower through phase 3 strengthening and return-to-sport progressions than patients with isolated procedures. Other Associated Anatomic Injuries Several specific types of soft tissue and bony injuries require modification to the standard rehabilitation guideline. An anterior labroligamentous periosteal sleeve avulsion (or ALPSA lesion) is an avulsion of the inferior glenohumeral ligament and anterior labrum with an intact scapula periosteum that allows the labrum and ligaments to displace medially and rotate inferiorly on the scapular neck (Figure 31). Repair of this injury usually warrants extra ROM limitations during the first 6 POWs. Stiffness in ER also might occur. Patients with repair of a humeral avulsion of the glenohumeral ligament (or HAGL lesion), which is a tearing of the anatomic humeral neck attachment of the inferior glenohumeral ligament (Figure 32), also The St. Francis Orthopaedic Institute & HPRC at St. Francis Rehabilitation Center 311