Rehabilitation following rotator cuff surgery

Rehabilitation Following Rotator Cuff Surgery Requires Change is the title of a release in Medical News Today.

The study, actually is a study of tendon-bone repair in the rat knee from which there has been an extrapolation to the treatment of the human rotator cuff.

The authors point out the dilemma surgeons face after rotator cuff repair surgery: immobilize to optimize healing or move to reduce the risk of stiffness. In the lab they cut and repaired the patellar tendon and then compared a low load motion program, a moderate load motion program and an immobilization program for up to four weeks after the repair. 

The tendon repairs that had been immobilized had stronger appearing bone at the repair site, stronger healing on load to failure tests and better looking histology in terms of tendon structure.  They suggest that immobilization may minimize inflammation which may favor the formation of scar tissue rather than healing at the repair site. 

There surely have been many studies showing that surgeons' attempts to re-establish rotator cuff integrity often fail. See our posts from October 2, 2011, April 1, 2012,  April 19, 2012, and June 4, 2012 as well as the classic article by Harryman.

In spite of all the recent work that has been done regarding special techniques in open and arthroscopic repair, the failure rate remains high, perhaps, as the authors of this article suggest, surgeons are trying to rehabilitate the shoulder too fast. Perhaps even more importantly, many torn rotator cuffs simply have insufficient quality and quantity to enable a durable repair. Some simple clinical observations seem to be predictive of repairability as we provided in the August 29, 2011 post.

For this reason, we emphasize to patients that repair is worth the prolonged rehabilitation period (even longer if we follow the recommendations of these authors) only if good quality tissue can be securely reattached to the anatomical insertion site without undue tension. Otherwise the patient may prosper more with a smooth and move procedure. Our approach is shown here.

An example of restoring comfort and function without attempting to re-establish cuff integrity is shown in the July 15, 2012 post.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

See the countries from which our readers come on this post.

Rotator Cuff 5 - Can the rotator cuff tear be repaired?

Yesterday's post covered some of the key factors bearing on the repairability of a rotator cuff tear.


Below are listed findings that have been shown to be encouraging or discouraging about the prospect of the shoulder having a durably reparable cuff tear. It is of interest that many of these factors can be determined without advanced testing.

ENCOURAGING                                          DISCOURAGING

History
    Age less than 55                                             Age over 65
    Acute traumatic onset                                     Insidious, atraumatic onset
    No relation to work                                        Attribution of tear to work
    Short duration of weakness                            Weakness over 6 weeks
    No history of smoking                                    Many smoking pack-years
    No steroid injections                                       Repeated steroid injections
    No major medications                                     Steroids/antimetabolites
    No concurrent disease                                     Inflammatory joint disease
    No infections                                                   History of previous infection
    No previous shoulder surgery                          Previous cuff surgery
    Benign surgical history                                    History of failed tissue repairs

Physical Examination
   Good nutrition                                                  Poor nutrition/obesity
   Mild weakness                                                  Severe weakness
   No spinatus atrophy                                          Severe spinatus atrophy
   Stable shoulder                                                 Anterior superior instability
   Intact acromion                                                 Previous acromioplasty
   No stiffness                                                       Stiffness

Radiographs
   Normal radiographs                                          Upwards head displacement
                                                                              Cuff tear arthropathy

MRI or Ultrasound                                            
  Good tendon quality                                         Thin tendon

  One tendon tear                                                 Multiple tendon involvement

  Small gap to close                                             Severe retraction

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Rotator Cuff 4 - Mechanisms of Tear, Factors Affecting Repair, "Impingement"

Initiation of Cuff Failure


Cuff fiber failure commonly results from the sudden application of eccentric loads, for example when the muscle attempts to resist a downward force on the arm

while the cuff seems to be better able to tolerate concentric loads, for example in a controlled lift away from the side. 

An anatomic factor predisposing to deep surface failure of the cuff insertion is internal abutment, where the corner of the glenoid contacts the deep aspect of the cuff at its tuberosity insertion 

This is most likely to be a problem for throwers who have stretched out their anterior capsule, allowing increased external rotation.



It is apparent that the most common form of cuff fiber failure, that which occurs on the articular surface of the cuff tendon, cannot be attributed to scuffing of the bursal surface by the acromion: so-called subacromial ‘impingement.’ In fact, the cuff insertion is well under the acromion at relatively small angles of elevation where it is protected from contact with the coracoacromial arch. Current evidence indicates that the most rotator cuff tears arise from tension overload and age-related attrition, rather than 'impingement'.

Readers might be interested in a recent review of the literature regarding the diagnosis of "impingement syndrome".

Factors Compromising Tendon Healing



Deep surface rotator cuff fiber failure exposes the defect to joint fluid. This joint fluid prevents the formation of a fibrin clot and, thus, healing is contravened.

Furthermore, tension at the edge of the cuff tear compromises the circulation to the margin of the tendon

For these reasons, left to their own devices, cuff defects tend to progress rather than healing. An optimal cuff repair surgery will bring healthy tendon into contact with vascularized bone and exclude joint fluid from the repair site. Subsequent posts will review the principles of surgical repair in some detail.


Factors Affecting Reparability

In considering the potential for surgically restoring a durable tendon insertion to bone, the surgeon needs to consider the quality of the tissue to be used in the repair. The ability of the cuff tendon tissue to withstand tensile loads is compromised by age, disuse, steroid injections, smoking, and poor general health. These predisposing factors can dispose the cuff tendons to fail with minimal force – essentially an atraumatic fiber failure. Cuff fibers that fail atraumatically may be so constitutionally weak that they cannot hold up even if repaired back to the bone. Thus, in chronic atraumatic cuff tears there is reason to consider a non-operative approach to improving shoulder function by rehabilitating the muscle–tendon units that remain intact.



Acute, traumatic cuff detachments that result from major force application are likely to be repairable

If acute traumatic cuff tears are not repaired promptly, the muscle may undergo intramuscular contracture, atrophy, and fatty degeneration and the tendon may become progressively reabsorbed. These degenerative changes compromise the opportunity for surgical repair. Thus, as with any other tendon avulsion from bone, time is of importance in the repair of acute tears of the rotator cuff. 

Loss of the rotator cuff subjects the superior glenoid to increased loads that can contribute to its erosion 

Progressive upward displacement of the humeral head produces secondary changes in the coracoacromial arch 

Once the humeral head has ascended so that its equator is above the residual cuff, contraction of the cuff muscles lock the humeral head in the superiorly displaced position

Chronic upwards displacement of the humeral head from cuff deficiency and superior glenoid erosion can result in cuff tear arthropathy,

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.