Rehab Summit Omni Orlando Resort at ChampionsGate Speaker: Terry Trundle, PTA, ATC, LAT

Rotator Cuff DecompressionThrough Tri-Plane Stabilization

FUNCTIONAL REHABILITATION OF THE SHOULDER

Open Kinetic Chain Rehabilitation Challenge

• Mobility – range of motion

• Recruitment – neuromuscular control

• Stabilization – tri-plane functionality

Three Phases of Rehabilitation

• Pre-functional – Mobility• Return to Function – Recruitment• Return to Activity – Tri-Plane Stabilization

Levels of Pathology

• Impingement• Partial thickness lesions

• Small – 1cm• Medium – 2-3cm

• Large (massive) tears• Full thickness >4-5cm• Complete rupture

• Irreparable tears

Signs/Symptoms of Rotator Cuff Dysfunction

• Compressive forces against the acromion• Mechanical irritation of the tendon• Thickening or fibrosis – Subacromial bursa

alterations• Bone spurs to tendon rupture –

Mechanical compression• Glenohumeral instability – Humeral head

translation

Concepts of the Three P’s

• Pivoters – scapular stabilizers i.e. rhomboids, trapezius, pectoralis minor and serratus anterior

• Protectors – rotator cuff

• Positioners – deltoids, latissimus dorsi, pectoralis major

Reference: Ellen m, Rogers DP, Gilhoal JJ: Practitioner Flexibility Strengthens Shoulder Rehabilitation Protocol. Biomechanics, January 2000; 45-52.

True Function of the Rotator Cuff

• Dynamic decompression of the humeral head by providing balance of the upper pull of the deltoids

• Steer and stabilize the humerus to the glenoid

• Result = smooth rotational movement to allow shoulder elevation

CKC vs. OKC Exercises: Shoulder

• Moveable – No Load (MNL) = passive

• Moveable – External Load (MEL) = OKC

• Fixed – External Load (FEL) = CKC

Reference: Dillman C. Murray, T., Hintermeister, R. 1994. Biomechanical Differences of Open and Closed Chain Exercises with Respect to the Shoulder. Journal of Sports Rhabilitaiton, 3:228- 238.

Clinical Examination Motion

Mobility:• Short lever arm rotation

– External rotation in modified scaption– Internal rotation – spine level

• Long lever arm movement– Elevation – transverse plane– Horizontal abduction at 90°– Abduction – modified scaption

Early Motion Concerns

• Why pendulum exercises need to be reconsidered

• Self-ROM with cane/wand is usually performed incorrectly

• Manual motion should begin in scaption• Rotation before elevation

Passive Micro-Mobility – Primary

• Scapular Release with diagonals• Lateral Glide and Tilt

• Glenohumeral Inferior Glide– Over the top– Finger mobility with passive rotation

• Glenohumeral posterior glideReference: Kumbhare DA, Basmajian JV. Decision Making

and Outcomes In Sports Rehabilitation. Chapter 19, 2000. Philadelphia, Churchill Livingstone.

Passive Micro-Mobility – Secondary

• AC and SC joints A-P micro-mobility

• Glenohumeral lateral glide

Clinical Examination ReviewRotator Cuff – Muscle Testing• Supraspinatus – Full can vs. empty can

• Drop arm test

• Infraspinatus/Teres Minor – External rotation lag

• Subscapularis: –Lift off test (lower)–Belly press test (upper)

Reference: Ellenbecker, TS: Clinical Examination of the Shoulder, St. Louis,2004, Elsevier Saunders (ch 11)

RECRUITMENTScapula Control

Retraction sets

• Theraband Rows• Seated Rows with Weights• Prone Scapular Retraction• Prone Horizontal Abduction (Fly) with Retraction

Reference: McCabe RA, Orishimo KF, McHugh MP, Nicholas SJ. Surface Electromyographic Analysis of the Lower Trapezius Muscle During Exercises Performed Below Ninety Degrees of Shoulder Elevation in Healthy Subjects. NO AM Journ Sports Phys Ther vol-2(1) 34-43;2007

Additional Scapula Control

• One arm rows with retraction• One arm rows on Swiss ball• Huggy bear with theraband

Reference: Porterfield JA, Derosa C: Mechanical Shoulder Disorders: Perspectives in Functional Anatomy. Philadelphia 2004. Saunders.Manske RC. Electomyographically Assessed Exercises For The Scapular Muscle. ATT 2006 11(5) 19-23.

Scapula Control

Protraction – Serratus Anterior

• Press-up plus – ceiling punch• Standing scaption to 120°• Wall push-ups plus• Push-ups plus – floor

Reference: Ekstrom RA, Bifulco KM, Lopau CJ, Andersen CF, Gough JR. Comparing the Function of the Upper and Lower Parts of the Serratus Anterior Muscle Using Surface Electromyography. J Orthop Sports Phys Ther 2004 34(5) 235-243.

Kelly IV JD. Scapular Disorders Stretch Focus of Athletic Rehabilitation. Biomechanics. July 2007: 20-28.

Positional Recruitment

Evidence based – EMG Studies• Sidelying External Rotation

• Prone Extension to hip

• Prone Horizontal Abduction with External Rotation

• Prone 90/90 External Rotation

Positional Recruitment• Scaption – thumb-down internal rotation• Scaption – neutral thumb-up position – Flexion• Bench Press• Press-up (chair dips)

References:Townsend, H. Jobe FW, Pink M., Perry J: Electromyographic Analysis of

the Glenohumeral Muscles During A Baseball Rehabilitation Program. Am. Journal of Sports Medicine, Vol. 19, No. 3, 1991 pp. 264-271

Blackburn TA, McLeada, WD, White B., Wofford L: EMG Analysis of Posterior Rotator Cuff Exercises. Athletic Training Spring 1990 pp. 40-45

Ellenbecker TS, Bleacher S. Method in Movement. Physical Therapy Products, Jan-Feb 2003. pp. 40-44

Modified Super Eight Therapeutic Value

• Sidelying external rotation• Scaption – Standing to 90°, 120°• Prone extension to hip• Prone scaption - 100°, 120°• Prone horizontal abduction with rotation• Prone external rotation 90/90 position• Push-ups• Chair-dips (press-ups)Reference: Reinold MM, Wilk KE, Fleisig GS, Et Al: Electromyographic

Analysis of the Rotator Cuff and Deltoid Musculature During Common Shoulder External Rotation Exercises. J Orthop Sports Phys Ther. 34 (7), 2004; 385-393.

CLOSED KINETIC CHAIN RECRUITMENT

• Ball on the Wall – Not true CKCMuscle Re-education

• Wall push-ups – Sagittal plane– Transverse Plane

• Wall push-up plus add resistance

Reference: Ellenbecker TS, Davies GJ: Closed Kinetic Chain Exercises: A Comprehensive Guide to Multiple-Joint Exercises. Champaign, IL. Human Kinetics, 2001.

University of Kentucky Studies

• Electromyographical Differences between slow and fast closed and open chain shoulder exercises– Fast speed OKC > CKC– CKC produced less EMG Activity than OKC– Supraspinatus Activity > in OKC than CKC

Reference: Uhl TL, Wise MB, Mattacola CG, Nitz AJ: Division of Athletic Training

CLOSED KINETIC CHAIN RECRUITMENT

• Push-up on uneven surface – ball on the wall• Wall push-ups while standing on uneven surface

– balance pad or BOSU• Hands on Stepper – straight/flexed elbow

References:1. Ellenbecker TS, Davies GJ: Closed Kinetic Chaine Exercises: A

Comprehensive Guide to Multiple – Joint Exericse. Human kinetics: 2001 . 87-98.

2. Uhl TL, Carver TJ, Matacola CG, Mair SD. Nitz AJ, Shoulder Musculature Activation During Upper Extremity Weight Bearing Exercise. Jour. Orhto Sports Physical Therapy. Vol 33, No 3, March 2003, pp. 109-117

3. Pontillo M, Orishimo KF, et al: Shoulder Musculature Activity and Stabilization During Upper Extremity Weight Bearing Activities. No. Am. Journal Sports Phys Ther: 2007 Vol 2, No 2, pp.90-96.

PLYOMETRIC EXERCISE FOR THE SHOULDER

PHASE I• Two Hand Chest Pass – Weight of ball based on patient• Two Hand Soccer Toss – Weight of ball based on patient• Two Hand Toss with single leg balance

PHASE II• One Hand Toss - Standing rotation at side• One Hand Retro Toss• One Hand Toss with single leg balance• One Hand Toss with balance pad/BOSU

Reference: Wilk K.E., Voight M. Plyometrics For the Shoulder Complex. In J. Andrews, K. Wilk, eds. The Athlete’s Shoulder. New York: Churchill Livingston 1993: 543-566Manske RC. Post Surgical Orthopedic Sports Rehabilitation Knee and Shoulder. Chapter 27 p.525, Chapter 31 p.621. 2006 St. Louis. Mosby-Elevier.

Impingement

• Sub-acromial Encroachment

• Humeral Head Depressor Deficiency

• Anterior Capsular and Deltoid Deficiency

• Posterior Capsular and Rotator Cuff Contracture

Acromial Architecture

• Type I – Flat• Type II – Curved• Type III – Hooked (highest % of RCT)

Reference: ManskeRC. Post Surgical Orthopedic Sports Rehabilitation Knee and Shoulder. Chapter 33, 2006. St. Louis Mosby-Elevier

Impingement Non-Operative Intervention (exercises)

• Scapula Stabilization – Retraction/Protraction• Mobility – Scapula – Glenohumeral

• Inferior & Posterior glides• Anterior Capsule – Pect Wall (Pectoralis)

• Rotator Cuff Strengthening• Posterior Cuff – Prone Series• Scaption• Side lying external rotation

• Wall Push-ups – closed kinetic chain

Impingement

Treatment - Operative

• Decompression – S.A.D.• Bevelling - Acromion• Detachment - Coraco-Acromion Ligament• Distal Clavical Excision

Impingement• Subacromial Decompression (SAD-DCE)

– Post operative Intervention Phase I• Manual mobility – Scapula/GH joints

– Distraction, posterior & Inferior glides– Posterior capsular stretch

• Scapula Stabilization• Closed Kinetic chain exercises

– Ball on Wall– Wall Pushups

• Rotator cuff Isometrics – Progress to Short arc Active Strengthening– T-Band Series

• Elbow, wrist & hand strengthening• UBE

Impingement

SAD – DCE – Phase II• Mobility as needed• Rotator cuff strengthening

– Scaption– Prone series– Sidelying external rotation

• Oscillatory Training – Body Blade• Advanced scapula - Stabilization

Impingement

SAD – DCE – Phase III• Progressive strengthening

– High reps – PRE• Press-ups (chair dips)• Manual PNF• Advanced Closed Kinetic Chain exercises• Plyo-toss• Sports Specific Activities

Vital Five Exercise Program Impingement

• Scapula Stabilization (advanced)– Prone Retraction– Scaption 120°

• Sidelying External Rotation• Prone Series• Scaption Standing• Single Arm wall push-up

– transverse plane

ROTATOR CUFF REPAIR

Arthroscopic vs. Mini-Open Repairs

Factors used to determine type of surgery• Tear size• Mobility of the tissue• Tissue quality• Age and activity level

Survey Conducted by Wilk, 2003Reference: Manske RC. Post Surgical Orthopedic Sports

Rehabilitation Knee and Shoulder. Chapter 33. 2006 St. Louis. Mosby-Elevier.

Arthroscopic vs. Mini-Open Repairs

• Less deltoid injury• Visualization of tear• Secondary pathology• Less post-op pain• Improved motion

Rotator Cuff RepairPartial thickness Lesions – small to medium tearsPhase I Pre-functional – 1-3 weeks• Immobilization as needed abduction pillow brace in

scapular plane• Manual control range of motion

– ER 45° at 45° of abduction– Elevation – short to long lever arm motion

• Wrist and grip exercises• Biceps and Triceps curls – neutral humerus• Ball on the wall/table – early closed kinetic chain• Scapular retraction sets• Sub-max isometrics

Manske RC. Post Surgical Orthopedic Sports Rehabilitation Knee and Shoulder. Chapter 33. 2006 St. Louis. Mosby-Elevier

Rotator Cuff RepairPartial thickness Lesions – small to medium tearsPre-Functional Phase 3 – 6 weeks• Manual control range of motion

– ER – progressive to 90° at 45° abduction to 90° abduction– Elevation 140° to WNL

• UBE when ready• Standing Extension to hip• Resistive strengthening – scapular retraction

– Add protraction when ready• Manual exercises – rhythmic stabilization• Wall push-ups (double arm) – closed kinetic chain exercises

• Begin prone series with prone extension to hip• Thera-band® short-arc rotation

Isotonic vs Elastic Resistance - EMG

• Tubing Exercises– Diagonal – PNF– Standing – Rotation

• Isotonic Exercises– Prone Series

Hughes, CJ, McBride, A: The Use of Surface Electromyographiy to Determine Muscle Activation During Isotonic and Elastic Resistance Exercises For Shoulder Rehabilitation. Orthopedic Practice 17 (2) 2005 18-23.

Rotator Cuff RepairPartial thickness Lesions – small to medium tearsReturn to function Phase

• Isotonic strengthening with positional recruitment– Prone series – prone extension to hip, prone horizontal abd –

ER, prone scaption– Scaption to 70° then to 90° - (Full Can)– Sidelying external rotation to neutral

• Elevation strengthening • Protraction PRE• Placement eccentrics• Advanced scapular stabilization• Rhythmic stabilization (perturbation)

Rotator Cuff Repairs

Partial thickness Lesions – small to medium tears

Return to function Phase• Closed kinetic chain exercises – wall push-ups

– Three planes – single arm – uneven surface• Manual PNF exercises• Plyo-toss – double arm – plyometrics• Bodyblade – three planes – oscillation training

Rotator Cuff Repairs

Partial thickness Lesions – small to medium tears

Return to activity Phase• Advanced strengthening – vital five program• Endurance training i.e. bodyblade® – impulse

training• Plyo-toss – plyometrics – single arm• Progress to single leg balance• Sports or job specific training• Interval throwing (if needed)

Rotator Cuff Repairs

Partial thickness Lesions – small to medium tears

Return to activity Phase• Vital Five Exercises – Home Program

– Scapula Stabilization– Single arm wall push-up– Prone series– Scaption strengthening– Sidelying external rotation

Rotation Cuff Repair

Full-thickness Tears – Large (massive)Pre-functional phase 1-3 weeks• Immobilization – abduction brace• Manual control ROM• Gripping exercises• Elbow ROM with neutral Humerus – light

strengthening– Begin Isometrics

• Sub-max Isometrics – end of week three

Rotator Cuff Repair

Full-thickness Tears – Large (massive)Early Post-op R.O.M.• Rotation in scapular plane 30° - 60°

– Less tension on repair• Repaired supraspinatus increased tension in 30°

to 60° of internal rotation• Elevation in scapular plane

– Neutral Humeral position with progressive external rotation < 60°

Rotator Cuff RepairsFull-thickness Tears – Large (massive)Pre-functional phase 3-6 weeks• Manual control ROM assisted elevation• Isometrics – deltoids and rotators – sub-max• Scapular stabilization – retraction – Thera-band ®

• Elbow strengthening – biceps/triceps PRE• Rhythmic stabilization• Thera-band® rotation short-arc at end of this phase• Standing extension to hip• Prone extension to hip• Closed kinetic chain – ball on the wall• UBE

Rotator Cuff RepairsFull-thickness Tears – Large (massive)Return to Function Phase• Continue manual ROM• Advanced scapular stabilization• Positional recruitment – prone series, scaption 70° - 90°,

sidelying, external rotation• Closed Kinetic Chain exercises – wall push-ups double

arm to single arm – 3 planes• Eccentric training as needed• PNF – manual exercises• Plyo-toss – double arm• Bodyblade® training for endurance

Rotator Cuff RepairFull-thickness Tears – Large (massive)Return to Activity Phase• Advanced plyo-toss – plyometric – single arm

toss• High reps with Bodyblade® for endurance• Progressive strengthening – open and closed

kinetic chain• Vital five exercise program• Sports or job specific training• Internal throwing (if needed)

Rehabilitation Summary• Tri-Planar Stabilization• Positional Recruitment

– Vital Five – Based on Therapeutic ValueStrengthening• Scapula-cuff stabilization using the three “p’s”

– Pivotors – scapular stabilizers, i.e., rhomboids & trapezius

– Protectors – rotator cuff– Positionors – deltoids, latissimus dorsi, pectoralis

major

Vital Five – Rotator Cuff Repair – Large (Massive)

• Scapular Stabilization – Retraction - Protraction

• Sidelying External Rotation• Prone Horizontal ABD – ER• Standing Scaption• Wall Push-ups transverse plane