REHABILITATION FOLLOWING SCR AND RTSA 2017 Ortho Summit December 9, - PowerPoint PPT Presentation

REHABILITATION FOLLOWING SCR AND RTSA 2017 Ortho Summit December 9, 2017 Ellen Shanley PhD, PT, OCS

I (and/or my co-authors) have nothing to disclose. Detailed disclosure information is available through the Orthopedic Summit

The Paradigm PROCEDURE PROBLEM TREATMENT IMPAIRMENT GOALS PATHOLOGY

rTSA compared to SCR

Influence on Choice & Progression Cuff Deficient ⇣ Function Shoulder Pseudo Pain Paralysis

Our Responsibility… Managing Expectations Appropriate For Each Patient

Implications for Rehabilitation Young ⇡ Age GOALS IMPAIRMENT Function vs Pain PATHOLOGY Massive RCT

Intra operative findings- rTSA  Type of implant/component  Humeral bone quality,  Deltoid status  Integrity of remaining RC,  Concomitant RC repair  Overall component stability.

Common complications RTSA  Scapular notching  Component Failure/ disassociation  Dislocation  Infection  Acromial Stress fracture

Key Concepts- rTSA  3 Key Rehab Concepts: 1. Joint protection 2. Deltoid function a. Remainder of RTC 3. Est appropriate functional goals a. ROM

Priorities AROM & ant ROM- 90º FE; Adv strength deltoid Strength 20º-ER Limit cycles No body wgt Submax Iso’s protect stability Limit cycles of & Limit stress Scapular Ex ROM Hold vs. cycles….

rTSA  rTSA higher risk for dislocation vs. conventional TSA (Boudreau et al., 2007)  Dislocation typically occurs in IR, adduction and extension (reaching behind back)

Early expectations 3-4 weeks….

DC Outcomes

Implications for Rehabilitation Young ⇡ Age GOALS IMPAIRMENT Function vs Pain PATHOLOGY Massive RCT

SCR Implications for Rehab  Allograft  Best tissue @ day 1 post-op  “soft tissue rTSA ” (Thay Lee, PhD)  Augmented massive RCR  Rotational stress  Tenodesis effect of subscapularis & infraspinatus  Long axis stress  Gravity  ”distraction” (Mihata et al AJSM ’16)

Intra-operative Findings- Expectations  Restoration of PROM  Amt Subscap/ Infra  Remaining Tissue  Mobilization  Position  AROM- Amount of native tissue

SCR Treatment Pathway  Massive RCR Pathway  Failure of Massive RCR- 98% in 1 st 6 months  Repairs of tears > 4cm fail < 12 wks ( Miller et al AJSM ‘11) ☐ Increased risk of “re-tear/non healing” with early AROM ☐ < 3cm early 1.63x ☐ > 3m early 2.5x ☐ > 5cm 6x

Priorities Education Protect Joint 5 weeks- healing tissue Protection distal UE & Protection ROM only Care Functional Box ER then FE- Mobility ROM ADL’s

Protected ROM Rehabilitation plan to match the surgery and the patient Graft type • Other cuff status • Patient goals/context •

Goals • Work • Sport Loading • Position • Reps Demands

Controlled Loading for Function >50% 40-60% 25-50% • All suggested exercises < 40% rotator cuff EMG

Great < 90 then Fight Gravity Restore Force Couple

Patient Outcome Expectation n=9 n=8

AROM Return After SCR

The real story on AROM return n= 22 n=12

Return to Function ➔ No heavy lifting 4-6 months ➔ Sport progressions o Golf > 20 weeks o Tennis >26 weeks o Swimming >26 weeks (Fealy S et al. ’02; McKee MD et al. 00; Ellman et al ‘86; Charousset et al ‘08)

Healing Time to Function