Exercises for Post Op Rotator Cuff Repair

Want to know the 9 best exercises for the early stages of post op rotator cuff repair. A Systematic Review from 2017, looked at EMG activity of over 45 different exercises and narrowed it down to these 9 with the least amount of rotator cuff EMG activity. Hint: not all pendulums are the same, and pulleys were not on the list.

Source:

A Systematic Review of Electromyography Studies in Normal Shoulders to Inform Postoperative Rehabilitation Following Rotator Cuff Repair Journal of Orthopaedic; Sports Physical Therapy 2017 47:12, 931-944 

• Identified passive and active assisted ROM exercises, using EMG, that would be most appropriate in the early/acute states following RC repair, to limit retear rates. Authors were looking for exercises that had <15% MVIC

• Retear rates are dependent on size of the tear; tissue quality; the location, type, and chronicity of the tear; previous and/or concomitant surgery; and individual patient factors such as smoking, body mass, and physical activity.

• A total of 43 different exercises were evaluated, with 9 meeting the cut off criteria of <15% MVIC.

• Most active assistive exercises using  a bar or a pulley to elevate the operated limb tended to generate over 15% MVIC, suggesting that their use early in rehabilitation may be inappropriate.

• For Supraspinatus: ER bar assisted (supine or standing) or wall assisted; supine press up (opp arm assist) , washcloth press up (hands close together); towel slides (flexion and scaption); pendulums (small); prone scapular retractions; scapular protraction on a swiss ball

• For Infraspinatus: forward bow, towel slides (flexion and scaption), scapular protraction on a swiss ball, supine self assisted; prone scapular retraction, washcloth press up (hands close together), pendulums (small), supine bar assisted ER (supine or standing).

Mentoring Minutes: Wrist Mobility Deficits

Today's reference article is an older one. However, the content and concepts are timeless and very helpful. Explore the article by clicking, HERE.

Mentoring Minutes: "Tennis Elbow"

“Tennis elbow”, lateral epicondylitis, lateral epicondylalgia. Have you ever wondered what research says about treating this condition? Enjoy the video below to learn about “tennis elbow”, and specific strategies to improve patients with lateral elbow pain.

Thanks for watching!

REFERENCES & NOTES:

• Cohen M, da Rocha Motta Filho G. LATERAL EPICONDYLITIS OF THE ELBOW. Rev Bras Ortop. 2012 Jul-Aug;47(4):414-20.

  • Epicondylitis suggests it is an inflammatory process, however, histological analysis shows that there are degenerative changes in the tendon. The tendon most commonly involved is ECRB, with the pain arising from active wrist extension or passive flexion of the wrist when the elbow is extended.

• Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014 Jan;28(1):3-19.

  • Eight studies found that after performing eccentric exercise (6-8 holds or 4 sec lowering), patients reported decreased pain, improved function and grip strength.

• Jiten B. Bhatt, Randal Glaser, Andre Chavez, Emmanuel Yung. (2016) Management of Lateral Epicondylalgia Targeting Scapular Muscle Power Deficits: A Case series. Journal of Hand Therapy 29:2, e5-e6. 

  • A case series suggested that patients with lateral epicondylalgia can be managed with middle and low trapezius strength by repositioning the scapula to a more neutral position.

• Day JM, Bush H, Nitz AJ, Uhl TL. Scapular muscle performance in individuals with lateral epicondylalgia. J Orthop Sports Phys Ther. 2015 May;45(5):414-24.

  • 28 patients with symptomatic lateral epicondylalgia and 28 controls were compared in regards to middle trapezius, lower trapezius, and serratus anterior muscle thickness. After using ultrasound imaging, this study suggests that the scapular muscles should be assessed and potentially treated in this population.

• Buchanan BK, Hughes J. Tennis Elbow (Lateral Epicondylitis) [Updated 2017 May 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan

  • A book describing the etiology, epidemiology, pathophysiology, histopathology, history and physical, evaluation, treatment, etc.

Mentoring Minutes: Cubital Tunnel Syndrome

Cubital Tunnel Syndrome:Part 1

Cubital Tunnel Syndrome: Part 2

REFERENCES & notes: 

Wojewnik B, Bindra R. Cubital tunnel syndrome — Review of current literature on causes, diagnosis and treatment. Journal of Hand and Microsurgery. 2009;1(2):76-81. doi:10.1007/s12593-009-0020-9.

- Most don’t need surgery, unless traumatic injury to elbow structure

- SOL: bone spur, ganglions, callus,

- Froment sign: weakness of adductor pollicus muscle, pt given a piece of paper and holds it together between the thumb and index finger (key pinch) with flexion of the thumb IP joint (because weakness of add poll muscle.

-Positive flexion sign at the elbow with supination and wrist extension reproducing the symptoms up to 60 seconds and ulnar nerve subluxation with elbow flexion can also be seen.

- Treatment: braces, to limit flexion

Cutts S. Cubital tunnel syndrome. Postgraduate Medical Journal. 2007;83(975):28-31. doi:10.1136/pgmj.2006.047456.

 - 2nd most common peripheral nerve entrapment

- The cubital tunnel is formed by the cubital tunnel retinaculum which straddles a gap of about 4 mm between the medial epicondyle and the olecranon

- intraneural pressure associated with elbow flexion are believed to be key issues

-shape of the tunnel changes from an oval to an ellipse with elbow flexion. narrows the canal by 55%. , this compression can hinder blood flow;

-Elbow flexion, wrist extension and shoulder abduction increases intraneural pressure by six times.

- persons at risk_ holding prolonged flexion, prolonged position (tools, phones), pitchers at late cocking phase stresses nerve and tend to have mild boney changes at the elbow;

- 4th and 5th fingers parasthesia, or motor changes (clawing or abduction of little fingers

- elbow flexion test, tinnel, ULTT ulnar

-treatments: avoid prolonged flexion, nerve mobility,

-Cent Eur Neurosurg. 2011 May;72(2):90-8. doi: 10.1055/s-0031-1271800. Epub 2011 May 4.

Cubital tunnel syndrome - a review and management guidelines.

Assmus H1, Antoniadis G, Bischoff C, Hoffmann R, Martini AK, Preissler P, Scheglmann K, Schwerdtfeger K, Wessels KD, Wüstner-Hofmann M.

-J Hand Ther. 2014 Jul-Sep;27(3):192-9; quiz 200. doi: 10.1016/j.jht.2014.02.003. Epub 2014 Feb 27.

Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain.

Day JM1, Willoughby J2, Pitts DG2, McCallum M2, Foister R2, Uhl TL3.

- J Manipulative Physiol Ther. 2010 Feb;33(2):156-63. doi: 10.1016/j.jmpt.2009.12.001.

Neurodynamic mobilization in the conservative treatment of cubital tunnel syndrome: long-term follow-up of 7 cases.

Oskay D1, Meriç A, Kirdi N, Firat T, Ayhan C, Leblebicioğlu G.

Mentoring Minutes: Elbow Stiffness

References & Notes

Filh GM, Galvão MV. POST-TRAUMATIC STIFFNESS OF THE ELBOW. Revista Brasileira de Ortopedia. 2010;45(4):347-354. doi:10.1016/S2255-4971(15)30380-3.

- stiff elbows presented a thin capsule with a disorganized collagen matrix, increased inflammatory cytokine levels and fibroblastic infiltration, thus characterizing a fibrotic and inflammatory condition

- combination of loss of extension associated with loss of forearm supination represents a severe limitation on certain activities 

- functional arc of the elbow is defined as a range of flexion-extension motion of 30° to 130° and pronosupination of 50° to –50. (10)On the other hand, loss of 50% of the mobility of the elbow represents a functional loss of 80% of limb function. Likewise, contracture of flexion greater than 45° gives rise to severe dysfunction regarding the capacity to position the hand in space

-treatment: mobs, stretches, and splints

Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Rehabilitation of the Overhead Athlete’s Elbow. Sports Health. 2012;4(5):404-414. doi:10.1177/1941738112455006.

- if the patient continues to have difficulty achieving full extension using ROM and mobilization techniques, a low-load, long-duration (LLLD) stretch may be performed to produce a deformation (creep) of the collagen tissue, resulting in tissue elongation.

- The patient lies supine with a towel roll or a foam pad placed under the distal brachium to act as a cushion and fulcrum. Light-resistance exercise tubing is applied to the wrist of the patient and secured to the table or a dumbbell on the ground (Figure 1). The patient is instructed to relax as much as possible for 10 to 15 minutes per treatment. The resistance applied should enable the patient to stretch for the entire duration without pain or muscle spasm. This technique is intended to impart a low load during a long-duration stretch. Patients are instructed to perform the LLLD stretches several times per day, totaling at least 60 minutes of total end range time. We typically recommend a 15-minute stretch, 4 times per day. This program has been referred to as a TERT program (total end range time)

- Open pack:

            - HU joint: 70 deg flexion, 10 deg supination

                        - Distraction treatment

            - HJ joint: Full ext and supination

                        -Radial treaction treatment

                        - Post glide for ext

                        - Ant glide for flexion

            - PRU joint: 70 deg flexion, 35 deg supination

                        - post glide for pronation

                        - Ant glide for supination

A prospective randomized control Trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness. JBJS. 2012:94 694-700