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Common Shoulder Injuries in the Work Setting  Shoulder injuries can include:

Shoulder Injuries

 Rotator cuff injuries

Surgical and Conservative Treatment Options

 Ligamentous damage: AC Joint or labrum  Repetitive injuries creating bursitis or tendinopathy  Biceps tendon injuries  Fractures (not discussed)

2 | Shoulder Injuries: Surgical and Conservative Treatment Options ©SelectMark 2015

Primary Joints 4 separate joints comprise the shoulder complex  Acromioclavicular  Glenohumeral  Scapulothoracic  Sternoclavicular

Glenohumeral Joint  Formed by the humeral head and glenoid fossa.  Allows large range of motion.

3 | Shoulder Injuries: Surgical and Conservative Treatment Options

4 | Shoulder Injuries: Surgical and Conservative Treatment Options

Glenoid Labrum

Glenohumeral Ligaments

 Increases contact area of GH joint by 50% - deepens the socket  Attachment site for Glenohumeral Ligs.

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 Three bands: superior, middle and inferior  Works with labrum  Help to provide support for front (anterior) portion of shoulder

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Muscles of the Shoulder Complex    

Deltoid Rotator Cuff Latissimus Dorsi Pectoralis Major

Axioscapular muscles  Serratus Anterior  Trapezius  Rhomboid major & minor  Pectoralis Minor  Levator Scapulae

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8 | Shoulder Injuries: Surgical and Conservative Treatment Options

Rotator Cuff Injuries

Rotator Cuff Tendinopathies  Tendinopathy is a term designating a problem or pathology with a tendon. These include:  Tendinitis: inflammation of the tendon  Tendinosis: a degeneration of the tendon  Tear: a disruption of the tendon

 All RC Tendinopathies primarily (90%) involve the supraspinatus tendon  The location of muscle and tendon contribute to the increased incidence of injury 9 | Shoulder Injuries: Surgical and Conservative Treatment Options

Rotator Cuff Tendinopathy

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Rotator Cuff Tendinopathy: Diagnosis

 Typically occurs with repetitive motions or specific trauma (fall)  Muscle imbalances or subacromial space limitations can contribute to dysfunction  Abnormal stress can cause inflammation of tendon and/or tearing of fibers of tendon

 Clinical exam can accurately determine large RC tears  Small RC tears or tendonitis present similarly to impingement and/or bursitis (or all may be present)  MRI is Gold Standard for diagnosis of small (=3 cm)

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12 | Shoulder Injuries: Surgical and Conservative Treatment Options

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Rotator Tendinopathy : Diagnosis

Rotator Cuff Tendinopathy : Treatment

 Patient demonstrates pain with active motions but minimal to no pain with passive motions  Patient typically moderately to significantly weak with external rotation  For larger tears pt often unable to reach above shoulder height (shoulder hiking)

 For RC tendonitis or small RC tears treatment follows impingement protocol

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14 | Shoulder Injuries: Surgical and Conservative Treatment Options

Rotator Cuff Tear: Surgical Management

Rotator Cuff Tear

 For medium to large tears RC needs to be repaired surgically  Surgery mostly performed arthroscopically and with a small incision (“miniopen”) but a few surgeons can repair only arthroscopically  Long term both patients do well

 Anti-inflammatories or cortisone shot  Patient’s typically do well as pain decreases and muscle strength and balance (especially scapular and RC muscles) improves

 Functional Outcome of the RTC repair is impacted by:  Age  Extent of tear  Location of tear  Number of tendons involved  Tissue quality  Size of tear  Surgical Technique  Presence of Associated shoulder pathology

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16 | Shoulder Injuries: Surgical and Conservative Treatment Options

Rotator Cuff Tear: Treatment

Rotator Cuff Tear: Treatment

      

 All patients that have undergone RTC repair do not progress at the same rate.  Clinicians must consider:

Goals of Rehabilitation Following Rotator Cuff Repair Protect the integrity of the rotator cuff repair Minimize postoperative pain and inflammation Restore passive range of motion Restore strength and dynamic stability of the shoulder Restore active range of motion Return to functional activities

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 Anatomy and Biomechanics  Underlying pathophysiology  Principles of tendon healing

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Rotator Cuff Tear: Keys to Treatment

Rotator Cuff Tear: Keys to Treatment

Restore full passive ROM as soon as possible  Passive range of motion should be as soon as possible following surgery with MD input with regards to repair integrity.

Restore dynamic humeral head control  This is likely the most important goal of postoperative rehabilitation, other than maintaining the integrity of the repair.  Must restore the rotator cuff’s ability to center the humeral head within the glenoid fossa to limit superior humeral head migration.

 There currently is some debate about the need for

immobilization vs. mobilization of rotator cuff repair patients.  Some surgeons opt for a period of 2-6 wks of immobilization especially in older patients or with larger tears. • There are no good studies indicating the advantages of a period of strict immobilization. 19 | Shoulder Injuries: Surgical and Conservative Treatment Options

20 | Shoulder Injuries: Surgical and Conservative Treatment Options

Rotator Cuff Tear: Keys to Treatment

Rotator Cuff Tear: Keys to Treatment

Maximize external rotation strength  Several studies have shown that ER strength takes the longest amount of time to restore after rotator cuff repair.  The longer this area is weak, the more difficult it will be to stabilize the joint

Restoration of normal scapular muscular recruitment patterns  RTC dysfunction will persist if proper scapular stabilizer strengthening is not completed.

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22 | Shoulder Injuries: Surgical and Conservative Treatment Options

Rotator Cuff Tear/Repair: Rehabilitation During The Four Phases of Healing

Rotator Cuff Tear/Repair: Rehabilitation

 Phase I Immediate post operative period (0-6 wks)  Goals

 Phase II Protective and Active Motion (6-12wks)  Goals

 Maintain/protect integrity of repair

 Allow healing of soft tissue

 Patient often placed in sling for 2-4 weeks.

 Do not overstress healing tissue

   

• Some MDs also use abduction Immobilizer to minimize RTC Tension Gradually increase PROM Diminish pain and inflammation Prevent muscular inhibition Become independent with modified ADLs

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 Gradually restore full PROM (weeks 4-5)  Decrease pain and inflammation  Begin AAROM and AROM  Begin RTC isometrics  Continue Periscapular ex

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Rotator Cuff Tear/Repair: Rehabilitation

Rotator Cuff Tear/Repair: Rehabilitation

 Phase III Early (10-16wks) Strengthening  Goals

 Phase IV Advanced (16-22wks) Strengthening  Goals

 Full AROM (weeks 10-12)

 Maintain full non-painful AROM

 Maintain full PROM

 Advanced conditioning exercises for enhanced functional

 Dynamic shoulder stability  Gradual restoration of shoulder strength, power, and

endurance

use  Improve muscular strength, power, and endurance  Gradual return to full functional activities

 Optimize neuromuscular control  Gradual return to functional activities

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26 | Shoulder Injuries: Surgical and Conservative Treatment Options

Labral Injuries

Labral Injuries: Diagnosis

 Labral tears typically occur after trauma – (FOOSH injury)  Shoulder may sublux or dislocate (humeral head moves past glenoid)  With traumatic dislocation – repeated dislocations or subluxations may occur  Repetitive motions may contribute to “wearing” of labrum

 Diagnosis can be made with clinical exam but Gold Standard is an MRI  An arthrogram may be performed – joint injected with dye then MRI performed

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28 | Shoulder Injuries: Surgical and Conservative Treatment Options

Labral Injuries: Limitations

Labral Tears: Treatment

 Patient typically has limited ROM and complains of pain in front and/or on-top of shoulder

 Conservative treatments:  Medications for pain and inflammation, cortisone injection  Restricted duty –especially limiting overhead reaching/lifting

 Patient may report feeling of “shifting” in the joint and be hesitant to move into outer ranges (especially out to side)

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 PT will focus on improving muscular strength of rotator cuff

and scapular muscles  Labrum does not heal but improving strength and stability

can return patient to full function

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Labral Tears: Treatment

Labral Tears: Treatment

 Surgical treatment is often needed for patients with:

 Post-op Physical Therapy:

 Moderate pain  Continued weakness or limited function

 Patient typically in immobilizing sling for 3-6 weeks (depends

on size of tear)

 Recurrent Subluxations or Dislocations

 From initial PT visit until 4-6 weeks focus is on PROM,

 Surgical repair is typically performed arthroscopically,

 No AROM

labrum is debrided and sutures are placed to anchor labrum

scapular strength, isometrics • Must limit External Rotation secondary to strain on repair – steady progression of ROM is ideal vs. quick recovery in motion (place increased stress on healing tissue)

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32 | Shoulder Injuries: Surgical and Conservative Treatment Options

Labral Tears: Treatment

Sub-acromial Impingement

 From 4-8 weeks goal in rehab is to progress AROM, regain full PROM and pt is allowed to begin resisted strengthening

 Injury typically results from repetitive motions, especially overhead reaching/lifting or trauma (fall)

 From 8-12 weeks functional lifting with increasing weight can be performed  Return to full duty varies from 3-6 months post-op depending on size of repair and work demands

 Sub-acromial bone spurs  can also create irritation

 Burse becomes inflamed and occupies increased space in sub-acromial region  Inflammation results in pain with reaching and lifting activities

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34 | Shoulder Injuries: Surgical and Conservative Treatment Options

Impingement: Diagnosis

Impingement: Treatment

 Diagnosis typically made with clinical exam  X-rays can be performed to check for bone spurs  MRI can be performed: will show inflammation in joint

 Impingement and partial-thickness tears of the rotator cuff usually are treated non-surgically

 Also to rule out other pathology (RC tear)

 Anti-inflammatories, Possible injection  These patients are good candidates for early PT

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36 | Shoulder Injuries: Surgical and Conservative Treatment Options

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Impingement: Treatment

Impingement: Treatment

 The rehabilitation goals include:  Reestablishing full ROM  Synchronizing the firing of the rotator cuff and periscapular muscles  Reestablishing normal glenohumeral and scapulothoracic kinematics.

 Exercise performed in positions that avoid both impingement of the rotator cuff tendons on the overlying acromial arch and further stress on the rotator cuff.  Elimination of posterior capsular contractures decreases the obligate anterosuperior translation of the shoulder, which minimizes contact between the rotator cuff and the acromion.  Appropriate strengthening of the infraspinatus, teres minor, and subscapularis permits the rotator cuff muscles to function in a concerted way to oppose superior humeral head translation and potentially reduce subacromial impingement. 

Millett PJ, Wilcox RB III, O’Holleran JD, Warner JJ. Rehabilitationof the rotator cuff: An evaluation-based approach. J Am Acad Orthop Surg 2006;14:599-609

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38 | Shoulder Injuries: Surgical and Conservative Treatment Options

Impingement: Treatment

Impingement: Treatment

 Manual physical therapy techniques(eg, joint mobilization) in conjunction with supervised exercise have been shown to be more effective than exercise alone in strength gains, pain reduction, and improved function.

 Most patients improve with conservative care in 3-6 weeks





Bang MD, Deyle GD: Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome.J Orthop Sports Phys Ther 2000;30:126-137. Conroy DE, Hayes KW: The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports Phys Ther 1998;28: 3-14

 Surgery may be needed if conservative care fails  Distal clavicular resection and sub acromial decompression

often performed

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40 | Shoulder Injuries: Surgical and Conservative Treatment Options

Impingement: Post-Op Treatment

Biceps Tendon

 Post-op SAD (sub-acromial decompression)  PROM 1-3 weeks, pt’s typically have moderate pain (bone

was shaved)  Progress AROM and strengthening from 2-4 weeks  Functional lifting 4-6 weeks  Typically released to full duty around 8-12 weeks

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42 | Shoulder Injuries: Surgical and Conservative Treatment Options

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Biceps Tendon

Biceps Tendon Injury

 Attaches Biceps muscle to shoulder complex through 2 tendons: short and long head  Short head attaches to coracoid process (part of scapula)  Long head attaches to glenoid fossa (part of socket) and blends with labrum

 Similarly to RC tears, biceps tendon can develop tendonitis or become partially or fully torn  Repetitive motions, lifting very heavy object or falls can contribute to injury  Biceps tendon (Long head) often involved with labral tears

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44 | Shoulder Injuries: Surgical and Conservative Treatment Options

Biceps Tendon: Diagnosis

Biceps Tendon: Treatment

 Clinical exam may find large tears but small tears will present like many other shoulder pathologies  MRI

 Conservative treatment including meds, injection and PT  PT focus on muscle balance and strength, improving shoulder mechanics that may be causing irritation (ie: forward shoulders)  For tendonitis or small tears conservative treatments are effective

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46 | Shoulder Injuries: Surgical and Conservative Treatment Options

Biceps Tendon: Treatment

Biceps Tendon: Treatment

 Surgery may need to be performed for large tears and may include debridement and re-attachment  Patient often placed in sling for 3-4 weeks  Early treatment focused on improving PROM (minimize stress to biceps)

 4-6 weeks progress AROM and initiate strength program  6-8 weeks further progress strength and functional lifting but no bicep curls (ie: lifting with elbow bent)  12 weeks biceps curls (lifting with bent elbows) is allowed  Most patients can return in 3-4 months post-op depending on injury and work demands

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48 | Shoulder Injuries: Surgical and Conservative Treatment Options

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Summary

References  Complex joint involving integrated motion at AC, SC, ST, GH & Spine.  20+ muscles for normal motion (direct and indirect).  High ability to compensate.

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       

Millett PJ, Wilcox RB III, O’Holleran JD, Warner JJ. Rehabilitation of the rotator cuff: An evaluationbased approach.J Am Acad Orthop Surg 2006;14:599-609 Kibler WB, McMullen J: Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg 2003;11:142-151. Bang MD, Deyle GD: Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther2000;30:126-137. Reinold MM: Biomechanical implications in shoulder and knee rehabilitation. In: Andrews JR, Wilk KE, Harrelson GL, editors. Physical rehabilitation of the injured athlete, third edition.Philadelphia: Elsevier, 2004, pp. 34-50. Wilk KE, Harrelson GL, Arrigo C: Shoulder rehabilitation. In: Andrews JR, Wilk KE, Harrelson GL, editors. Physical rehabilitation of the injured athlete, third edition. Philadelphia: Elsevier, 2004, pp. 513-589. 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. 2004;34:385-394. Outcomes After Arthroscopic Revision Rotator Cuff Repair Dana P. Piasecki, Nikhil N. Verma, Shane J. Nho, Sanjeev Bhatia, Nicole Boniquit, Brian J. Cole, Gregory P. Nicholson Am J Sports Med 2010 38: 40 Patients with Workers' Compensation Claims Have Worse Outcomes after Rotator Cuff Repair. J Bone Joint Surg Am. 2008;90:2105-2113. doi:10.2106/JBJS.F.00260 R. Frank Henn, III, Lana Kang, Robert Z. Tashjian and Andrew Green

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