Special Considerations for Concomitant Procedures in the Setting of Rotator Cuff Repair

Matthew S. Kearns PT, DPT, Cert. DN, Cert. SMT, Dip. Osteopractic,

FAAOMPT

Biceps Tenodesis & Tenotomy

• Present in almost all

subscapularis repairs1

• Know the anatomy and avoid

precarious positions

• Anatomy Review

What to Expect with Biceps Tenotomy

• Less effect on the rehab process2 – 2 weeks no active Elbow Flexion

– Delayed strengthening doctor dependent • 4-8 weeks light strengthening

• 8-12 weeks heavier strengthening

• Potential Side Effects3 – Popeye deformity

– Biceps cramping

Adjustments to Protocol with Biceps Tenodesis

Author Immobilized Weeks 0-4 Weeks 4-6 Weeks 6-12 Weeks 12+

Galasso et al.2 3 weeks Pendulums PROM/AAROM of elbow

Not described Light Strengthening

Light sports activity

Kahlenberg et al.4

4 weeks PROM of elbow & AROM after 2-3 days

Not described Reistance & weight training

Not described

Mazzoca et al.5

4 weeks AAROM elbow AROM elbow Strengthening Strengthening

Koh et al.6 4 weeks ROM exercises ROM exercises Strengthening Not described

Adjustments to Protocol with DCE7 Week 1-4 4-8 8-12

DCE • PROM to AROM as tolerated

• No horizontal adduction

• ROM goals 140˚ flexion and 40˚ ER

• ER/ABD combined avoided

• AROM increased all directions with PROM at end range

• ROM increased to 160˚ flexion and 60˚ ER

• Light isometrics • No horizontal

adduction

• Strengthening advanced from t-band to weights

• ROM to full

Subscapularis Repair Anatomical Review

Origin: Medial 2/3 of anterior scapula1

Insertion:1 • Superior ½ wide uppermost aspect of

lesser tubercle

• Inferior ½ less wide anteromedial aspect of lesser tubercle

• Upper 2/3 tendinous insertion

• Lower 1/3 muscular insertion

Comma Anatomical Footprint of Subscapularis

Subscapularis Repair

Actions:8

• Internal rotation of humerus

• Dynamic Stabilization of humeral head

• Force couple as antagonist to superior pull of deltoid

• Position dependent » Flexion assist

» Abduction assist

» Adduction assist

General Consenus on Modifications in Literature for Subscapularis Repair • Piponov et al.1

– Weeks 0-2 PROM • Flexion to 90˚

• ER to 30˚

• IR to abdomen

– Weeks 2-6 PROM • Gradual increase of ER as tolerated

• Forward flexion to 130˚

– Weeks 6-12 • AROM started

– Weeks 12-16 • Strengthening begins without

jeopardizing repair

• Burkhart & Brady9 – Weeks 0-6

• ER to 0˚ – If partial subscapularis ER to 30˚

• No overhead motion

– Weeks 6-12 • AAROM and AROM as tolerated

– Weeks 12-16 • Strengthening tear size dependent

Why the variance in ER for first 6 weeks? Upper Vs. Lower Belly10

Motion Flexion ABD ER Neutral ER Scap Plane Protocol Effect

Upper Minimal Lengthening

Compression Linear Strain Linear Strain Flexion/ABD in safe zone

Lower Linear Strain Linear Strain Linear Strain Linear Strain Limit Elevation

How Much Motion is Too Much?

• Sano et al.11 – Linear relationship between tear size

and ER limitation

– Horizontal abduction and ER are to be done with care

• Haering et al.12 – Safe volume of movement decreases

as tear size increases

– Safety zones are least in supra+subscap repairs

– Flexion safer than abduction for supra+subscap tears

– Elevation above 75˚ (110˚ with scapular motion) jeopardize integrity

– Full amplitude PROM abduction, scaption, flexion can cause repair failure

Avoiding Repair Failure • Systematic review shows no RC repair protocol superior to another at this point13

• 98% of patients who fail to heal failure occurs in first 6 months14

• Larger tears 78% fail in the first 3 months14

• Patient education is HUGE14

• Stiffness isn’t as big of a problem as we think – Incidence about 4.9% of all cases15

• Arthroscopic lysis resulted in normal motion for all cases

– Identify at risk and introduce early close chain PROM16 & 17

• Sometimes less is more16 – Complication vs. Failure

• Protocols should not substitute for critical thinking14 – Customization

– Communication

Closing Thought

“Effective communication and coordination of care by the physical therapist and shoulder surgeon are essential in optimal patient outcomes after rotator cuff repair. In the ideal situation, a well-educated therapist who has great communication with the treating surgeon can customize therapy for each patient and mobilize the shoulder early, reestablish scapulothoracic function, and minimize the risk of stiffness and re-tear, while facilitating return to function. However, the ideal situation is often not attainable”18

References 1. Piponov, H. I., Toor, A. S., & Shi, L. L. (2015). Arthroscopic Subscapularis Repair. Operative Techniques in Orthopaedics, 25(1), 33-42.

2. Galasso, O., Gasparini, G., De Benedetto, M., Familiari, F., & Castricini, R. (2012). Tenotomy versus tenodesis in the treatment of the long head of biceps brachii tendon lesions. BMC musculoskeletal disorders, 13(1), 205.

3. Virk, M. S., & Cole, B. J. (2016). Proximal biceps tendon and rotator cuff tears. Clinics in sports medicine, 35(1), 153-161.

4. Kahlenberg, C. A., Patel, R. M., Nair, R., Deshmane, P. P., Harnden, G., & Terry, M. A. (2014). Clinical and biomechanical evaluation of an all-arthroscopic suprapectoral biceps tenodesis. Orthopaedic journal of sports medicine, 2(10), 2325967114553558.

5. Mazzocca, A. D., Cote, M. P., Arciero, C. L., Romeo, A. A., & Arciero, R. A. (2008). Clinical outcomes after subpectoral biceps tenodesis with an interference screw. The American journal of sports medicine, 36(10), 1922-1929.

6. Koh, K. H., Ahn, J. H., Kim, S. M., & Yoo, J. C. (2010). Treatment of biceps tendon lesions in the setting of rotator cuff tears prospective cohort study of tenotomy versus tenodesis. The American journal of sports medicine, 38(8), 1584-1590.

7. Sellards, R., & Nicholson, G. P. (2004). Arthroscopic distal clavicle resection. Operative Techniques in Sports Medicine, 12(1), 18-26.

8. Gausden, E. B., McCarthy, M. M., Kontaxis, A., Corpus, K. T., Gulotta, L. V., & Kelly, A. M. (2016). Subscapularis tendon loading during activities of daily living. Journal of Shoulder and Elbow Surgery.

9. Burkhart, S. S., & Brady, P. C. (2006). Arthroscopic subscapularis repair: surgical tips and pearls A to Z. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 22(9), 1014-1027.

10. Knesek, M., Brunfeldt, A., Korenczuk, C., Jepsen, K. J., Robbins, C. B., Gagnier, J. J., ... & Bedi, A. (2015). Patterns of strain and the determination of the safe arc of motion after subscapularis repair—A biomechanical study. Journal of Orthopaedic Research.

11. Sano, T., Aoki, M., Tanaka, Y., Izumi, T., Fujimiya, M., & Yamashita, T. (2014). Glenohumeral joint motion after subscapularis tendon repair: an analysis of cadaver shoulder models. Journal of orthopaedic surgery and research, 9(1), 41.

12. Haering, D., Blache, Y., Raison, M., & Begon, M. (2015). Mechanical risk of rotator cuff repair failure during passive movements: A simulation-based study. Clinical Biomechanics, 30(10), 1181-1188.

References Continued 13. Thomson, S., Jukes, C., & Lewis, J. (2016). Rehabilitation following surgical repair of the rotator cuff: a systematic review. Physiotherapy,

102(1), 20-28.

14. Thigpen, C. A., Shaffer, M. A., Gaunt, B. W., Leggin, B. G., Williams, G. R., & Wilcox, R. B. (2016). The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation following arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery, 25(4), 521-535.

15. Huberty, D. P., Schoolfield, J. D., Brady, P. C., Vadala, A. P., Arrigoni, P., & Burkhart, S. S. (2009). Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 25(8), 880-890.

16. Denard, P. J., Lädermann, A., & Burkhart, S. S. (2011). Prevention and management of stiffness after arthroscopic rotator cuff repair: systematic review and implications for rotator cuff healing. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 27(6), 842-848.

17. Koo, S. S., Parsley, B. K., Burkhart, S. S., & Schoolfield, J. D. (2011). Reduction of postoperative stiffness after arthroscopic rotator cuff repair: results of a customized physical therapy regimen based on risk factors for stiffness. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 27(2), 155-160.

18. Koo, S. S., & Burkhart, S. S. (2010). Rehabilitation following arthroscopic rotator cuff repair. Clinics in sports medicine, 29(2), 203-211.

Picture Credit

1. https://www.shoulderdoc.co.uk/images/uploaded/bicep%20heads2.jpg

2. https://d1yboe6750e2cu.cloudfront.net/i/41aadd9d1fbef7bc13c0456d1714a57961d527a0

3. https://upload.wikimedia.org/wikipedia/commons/thumb/3/31/Tuberculumminushumeri.png/250px-Tuberculumminushumeri.png

4. https://image.slidesharecdn.com/cordascocurrentconceptsrctrepairmethodspt-110926084405-phpapp02/95/repair-methods-for-full-thickness-rotator-cuff-tears-implications-for-pt-29-728.jpg?cb=1317028252