Treatment 1
Management Surgery Rotator Cuff Rehabiliation Anterior Deltoid Re-education 2
Indications for surgery/ onward referral Acute symptomatic tears in people <65 years due to recent trauma 6/12 Unsuccessful trial of non-operative treatment including steroid injection Diagnostic uncertainty Neurological lesion Infection 3
Operative Treatment Arthroscopic Evaluation (can often be combined with treatment) Debridement Repair of partial thickness tear Repair of small full-thickness tears Open Repair In presence of full thickness tear and muscle retraction Poor tissue quality Weak bones 4
Rotator Cuff Rehabilitation 1. Relative Rest / unloading 2. Strength Rehabilitation 3. Return to Function 5
1) Relative Rest / unloading Decrease Pain and inflammation Medication (NSAID s, steroid injection) Relative rest/ movement modification Restoration and maintenance of ROM Passive movements / mobilisations Self-assisted exercises (wall-slides, stick, opp. hand) Pendular exercises (no pain) Gym ball Reduce Atrophy Scapular stabilisers, elbow/wrist, lower limbs 6
2) Strength Rehabilitation Consider starting when pain only during movement Increase Muscle Strength and Coordination Exercise in pain free range and gradually increase IR much later in rehab than ER Consider: Standing, prone, side lying PNF patterns Increase number of repetitions before increasing weight 7
3) Return to Function Progression to functional activities Restoration of sensory-motor control Closed-chain exercises (Wall push-ups, push-ups, wobble board, ball(s)) Open-chain exercises (catch ball, throw ball to targets, bounce ball, throw ball with resistance tubing on arm) 8
Anterior Deltoid Re-education Research was sparked by the observation that some patients with massive rotator cuff tears presented asymptomatic Wirth et al (1997) mentioned that The anterior deltoid is the most important muscle of the shoulder girdle, and special emphasis must be placed on strengthening of this structure as decreased anterior deltoid strength greatly limits function. 9
Research / Evidence 1. Ainsworth R (2006) Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears. Musculoskeletal Care 4: 140-151. 2. Levy O et al (2008) The role of anterior deltoid re-education in patients with massive irreparable degenerative rotator cuff tears. Reading Shoulder Unit, Berkshire Hospital. 10
Ainsworth (2006) Pilot study (10 patients) Evaluating a rehabilitation programme (=Torbay Programme) which included anterior deltoid strengthening and functional rehabilitation Patients attended ½ hour weekly for 4 weeks, then at 2-3 weekly intervals with progressing home exercises Outcome evaluation after 12 weeks Outcome measure was the Oxford Shoulder Disability Questionnaire (OSDQ) All 10 patients had improved 11
The Torbay Programme Patient education Posture correction Re-education of muscle recruitment Strengthening (mainly anterior deltoid) Stretching Improving proprioception Adaptation 12
13
Levy et al (2008) Prospective study (17 patients) The patients were treated with an anterior deltoid rehabilitation programme Patients were given standard detailed instruction and an illustrated guide Patients were reviewed after a minimum of 9 months 14 patients regained a good ROM and did not need any pain medication 3patients did not have adequate improvement 14
Reading Shoulder Unit Anterior Deltoid Exercises Advice for Patients with Massive Rotator Cuff Tears Written patient education Exercises must be done for at least 12 weeks, 3 to 5 times a day Exercises: Gentle pendulum movement for about 5 minutes Progression of lying down exercises Progression of same exercises in sitting Progression of same exercises in standing Stop exercising if your pain increases or you feel unwell You will be reviewed at 6 and 12 weeks 15
Supine I 16
Supine II 17
Supine III 18
Sitting 19
Standing 20
Summary Surgery Rotator Cuff Rehabiliation Anterior Deltoid Re-education Evidence based on small studies Widely accepted and used Seems to work Eccentric Anterior Deltoid Training is a phrase commonly used but no evidence for using only eccentric contractions 21
References Ainsworth R (2006) Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears. Musculoskeletal Care 4: 140-151. Ainsworth R, Lewis J (2007) Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. Br J Sports Med; 41: 200-210. Donatelli RA (2004) Physical Therapy of the Shoulder. Churchill Livingstone. Garg S et al (2010) Managing rotator cuff disorders. Arthritis Research UK, Reports on Rheumatic Diseases, Series 6, Topical Reviews No 7. Levy O et al (2008) The role of anterior deltoid re-education in patients with massive irreparable degenerative rotator cuff tears. Reading Shoulder Unit, Berkshire Hospital. Lewis J (2009) The Shoulder, Theory and Practice, Course notes, Health Education Seminars. Malanga GA et al (2009) Rotator cuff injury. Emedicine.medscape.com. Wirth MA et al (1997) Non-opertative management of full-thickness tears of the rotator cuff. Orthopaedic Clinics of North America, Vol 28, Issue 1. 22