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This Concept Map, created with IHMC CmapTools, has information related to: RC Tear, RC Tear ???? Interventions (Frequency, Intensity, time, type) HEP - Ice 20 minutes on, at least 2 hours before reapplying - Wear sling during day and while sleeping, except for showering - Starting week three begin passive pendulums, towel press-up, forward bow, towel slide, supine PROM, and scapular protraction with ball on table Week 1 - Gentle supine PROM scaption and ER with elbow at side - Manage pain/inflammation via cryotherapy and/or e-stim - AROM hand, wrist, elbow, and neck - Ball squeezes - Stationary biking or non-treadmill walking with sling on Week 2 - Grade 1 and 2 shoulder joint mobilizations for pain relief and reduce guarding - PROM flexion, extension, abduction, ER, and slight IR - AROM scapular retraction and depression - AROM all cervical motions - Ball squeezes - Manage pain/inflammation via cryotherapy and/or e-stim - Stationary biking or non-treadmill walking with sling on Week 3 - Implement HEP - Small circle pendulums - Isometrics hand, wrist, elbow, and neck - Grade 1 and 2 shoulder joint mobilizations for pain relief - Scapular retraction and depression isometrics - PROM flexion, extension, abduction, ER, and slight IR - Stationary biking or non-treadmill walking with sling on Week 4 - Submax shoulder isometrics in neutral - Isometrics hand, wrist, elbow, and neck - Progress from PROM to AAROM - AAROM supine shoulder flexion with dowel - AAROM standing shoulder ER and easy IR - Grade 1 and 2 shoulder joint mobilizations, Subjective Age- older is indication of degenerative tear MOI/cheif complaint- repetative overhead injury(microtruama), FOOSH (macrotruama), lifting something too heavy with a jerking motion (macrotruama) Pain rating/type/location: pain around the acromialhumeralspace and sometimes down the arm, pain raiting will depend on person, pain is usually a dull ache or if macro truamma a quick intense pain ease pain- limited use, No overhead movements worsen pain- overhead movement, jerking shoulder up, night pain when laying of affected side, sustatined overhead activitiy Red Flag questions- night pain, sudden weight loss, other pt visits, bowel and bladder issues , dizziness, blurred vision, fever, pain unrealated to activity, pain not reduced by rest, smoking Past medical history- history of falls, pervious RC injuries, surgeries, other shoulder issues PFHx- cancer, CV issues, pulmonary issues, imiaging Activity- overhead activity (job or recreational) ???? Prognosis In general, prognosis is good to excellent for individuals to return to pain free, full ROM following arthroscopic RC tear surgery. Better clinical outcomes and shorter rehab times associated with younger patients, with fewer RC muscle involvement, smaller tear size(s), male, higher BMD, Absence of DM, higher level of sports activity, greater preoperative shoulder ROM, absence of obesity, smaller sagittal size of lesion, less retraction of cuff, less fatty infiltrtion, no concomitant biceps or acromioclavicular joint procedures, RC Tear ???? Pathophysiology -Primary impingment -Secondary impingment -Hypermobility of the humoral head, Surgical Interventions Open Repair- open surgical incision often a few centimeters in length over the shoulder, deltoid is deached to have better visual of RC muscles *** can be used to remove bone spurs from acromion, used for complex or additional recontructions All-Arthroscopic Repair - uses a small camera to guide surgery, uses smaller incisions and least invasive method Mini-Open Repair - incision is shorter than open, and uses arthrocopeto assess and treat other stuctures such as the acromion, avoids detaching deltoid, then RC repair is done through incision. ???? Non-Operative Management -NSAID -Rest and reduction of overhead activity -Coricosterioid injection **note: these do not have great long term outcomes, RC Tear ???? MOI Traumatic injury to shoulder, typically involving FOOSH - Unexpected force when pushing/pulling - Shoulder dislocation - Repetitive microtrauma over time, typically from overhead use of arms - Compromisation of tissue quality with age, osteoarthritis, RC Tear ???? Tear Characteristics - Tear characteristics are often taken into consideration when determining rehab protocol - Partial vs. Full thickness -Size Small: əcm Medium: 1-3cm Large: 3-5cm Massive: ɱcm, Key Factors -Age -PMH as related to RC pathology -Activity level/type of activity -Degree of hypermobility ???? Subjective Age- older is indication of degenerative tear MOI/cheif complaint- repetative overhead injury(microtruama), FOOSH (macrotruama), lifting something too heavy with a jerking motion (macrotruama) Pain rating/type/location: pain around the acromialhumeralspace and sometimes down the arm, pain raiting will depend on person, pain is usually a dull ache or if macro truamma a quick intense pain ease pain- limited use, No overhead movements worsen pain- overhead movement, jerking shoulder up, night pain when laying of affected side, sustatined overhead activitiy Red Flag questions- night pain, sudden weight loss, other pt visits, bowel and bladder issues , dizziness, blurred vision, fever, pain unrealated to activity, pain not reduced by rest, smoking Past medical history- history of falls, pervious RC injuries, surgeries, other shoulder issues PFHx- cancer, CV issues, pulmonary issues, imiaging Activity- overhead activity (job or recreational), RC Tear ???? Differential Diagnosis - Acromioclavicular dislocation - dislocation of the acromioclavicular joint - Labral tear - could be bankart (anterior side of labrum of glenoid) or SLAP (superior labral anterior ro posterior) - Capsular tear- form of shoulder instability - Adhesive capsulitis - caracterized by stiffness and pain in the shoulder joint - Ligament tear - ruputure or tear of the superior, middle, or inferior glennohumeral ligament - Cervical radiculopathy - numbness or tingling steming from the cervical spine and will worsen or improve with neck ROM - Nerve entrapment, particularly subscapular and/or suprascapular n. - Osteoarthritis - - Rheumatoid arthritis - Calcific tendonitis - calcification of a tendon - Biceps tendinopathy - inflammation of the biceps tendon specifically the proximal tendon - Cancer, RC Tear ???? Pathology A tear (partial or full thickness) of one of the four rotator cuff muscles -Subscapularis -Infraspinatus -Teres minor -Supraspinatus, Subjective Age- older is indication of degenerative tear MOI/cheif complaint- repetative overhead injury(microtruama), FOOSH (macrotruama), lifting something too heavy with a jerking motion (macrotruama) Pain rating/type/location: pain around the acromialhumeralspace and sometimes down the arm, pain raiting will depend on person, pain is usually a dull ache or if macro truamma a quick intense pain ease pain- limited use, No overhead movements worsen pain- overhead movement, jerking shoulder up, night pain when laying of affected side, sustatined overhead activitiy Red Flag questions- night pain, sudden weight loss, other pt visits, bowel and bladder issues , dizziness, blurred vision, fever, pain unrealated to activity, pain not reduced by rest, smoking Past medical history- history of falls, pervious RC injuries, surgeries, other shoulder issues PFHx- cancer, CV issues, pulmonary issues, imiaging Activity- overhead activity (job or recreational) ???? Prevalence 22.1% have an RC injury with asymptomatic twice as likely as symtomatic 13% of individuals in their 50s 25% of individuals in their 60s 50% of individuals in their 80s, Subjective Age- older is indication of degenerative tear MOI/cheif complaint- repetative overhead injury(microtruama), FOOSH (macrotruama), lifting something too heavy with a jerking motion (macrotruama) Pain rating/type/location: pain around the acromialhumeralspace and sometimes down the arm, pain raiting will depend on person, pain is usually a dull ache or if macro truamma a quick intense pain ease pain- limited use, No overhead movements worsen pain- overhead movement, jerking shoulder up, night pain when laying of affected side, sustatined overhead activitiy Red Flag questions- night pain, sudden weight loss, other pt visits, bowel and bladder issues , dizziness, blurred vision, fever, pain unrealated to activity, pain not reduced by rest, smoking Past medical history- history of falls, pervious RC injuries, surgeries, other shoulder issues PFHx- cancer, CV issues, pulmonary issues, imiaging Activity- overhead activity (job or recreational) ???? Patient Profile -Younger (ម) may present post trauma Often involved in overhead sports or activities -Older (ᡠ) may present with a more insidious onset Often due to degenerative changes Can also be due to trauma, Imaging Selection American College of Radiology Appropriateness Criteria -Traumatic Shoulder pain variant 1 Radiographs -Traumatic Shoulder pain variant 8 MRI Ultrasound -Atraumatic shoulder pain variant 1 Radiographs -Atraumatic shoulder pain variant 3 MRI Ultrasound ???? Imaging Radiographs: -Can be utilized to rule out other suspected conditions like fracture, OA, calcific tendinitis -Superior migration of humeral head can implicate rotator cuff compromise Magnetic Resonance Imaging: -Allows a more global view of the shoulder than other imaging techniques -Can effectively assess tendons for abnormalities -Sp=92.9% for full thickness tears and 91.7% for partial thickness tears Ultrasonography: -Similar to MRI, can effectively assess soft tissue like tendons and muscles -Effectively assesses fatty degeneration and muscular atrophy that may occur secondary to RC tear -Limited capability to assess interosseous structures -Sp=94.4% for full thickness tears and 93.5% for partial thickness tears, Plan of Care 2x/week + HEP 1 hour sessions x4 weeks ** If pain with PROM is primary barrier: -Schedule 1x/week until controlled If stiffness is primary barrier to PROM: -Schedule 2x/week plus HEP ???? Interventions (Frequency, Intensity, time, type) HEP - Ice 20 minutes on, at least 2 hours before reapplying - Wear sling during day and while sleeping, except for showering - Starting week three begin passive pendulums, towel press-up, forward bow, towel slide, supine PROM, and scapular protraction with ball on table Week 1 - Gentle supine PROM scaption and ER with elbow at side - Manage pain/inflammation via cryotherapy and/or e-stim - AROM hand, wrist, elbow, and neck - Ball squeezes - Stationary biking or non-treadmill walking with sling on Week 2 - Grade 1 and 2 shoulder joint mobilizations for pain relief and reduce guarding - PROM flexion, extension, abduction, ER, and slight IR - AROM scapular retraction and depression - AROM all cervical motions - Ball squeezes - Manage pain/inflammation via cryotherapy and/or e-stim - Stationary biking or non-treadmill walking with sling on Week 3 - Implement HEP - Small circle pendulums - Isometrics hand, wrist, elbow, and neck - Grade 1 and 2 shoulder joint mobilizations for pain relief - Scapular retraction and depression isometrics - PROM flexion, extension, abduction, ER, and slight IR - Stationary biking or non-treadmill walking with sling on Week 4 - Submax shoulder isometrics in neutral - Isometrics hand, wrist, elbow, and neck - Progress from PROM to AAROM - AAROM supine shoulder flexion with dowel - AAROM standing shoulder ER and easy IR - Grade 1 and 2 shoulder joint mobilizations, PT Goals Week 1 - Wound care, edema and pain management, postural awareness, compliance with precautions, use of sling, proper dressing and washing techniques to maintain precautions Week 2 - Same as week 1, including protecting the repair, prevent negative effects of immobilization, and work towards PROM flexion of 100, ER 20, and abduction 60 Week 3 - Same as weeks 1 & 2, including promoting proprioception and scapulo-humeral rhythm, and PROM flexion 130, ER 40, and abduction 75 Week 4 - Same as previous including restoring functional use of the involved extremity, promoting dynamic stability and proprioception, and PROM flexion 140, ER 50, abduction 80, and restoring AROM ???? Phases Phase I: At least 14 days post op Passive forward elevation 60-90 degrees Passive ER to 20 degrees at 20 degrees of abduction Phase II: At least 8 weeks post op Passive forward elevation 90-120 degrees Passive ER to 20-30 degrees at 20 degrees of abduction Phase III: Passive forwar elevation to at leaast 140 degrees or full Passive ER at 20 degrees of abduction to at least 30-full. Passive ER at 90 degrees of abduction at least to 75 degrees to full Active elevation to at least 120 degrees without compensation Appropriate static and dynamic scapular positioning Phase IV: Not all patient progress to phase V - reserved for individuals that are involved in sports and physical labor Full shoulder AROM in all planes and multi-plane movements MMT of 5/5 in neutral Pain free during strengthenging exercises Negative impingment signs Phase V: Pateint may return to sport after receiving clearance from surgeon and rehab provider, RC Tear ???? Surgical Interventions Open Repair- open surgical incision often a few centimeters in length over the shoulder, deltoid is deached to have better visual of RC muscles *** can be used to remove bone spurs from acromion, used for complex or additional recontructions All-Arthroscopic Repair - uses a small camera to guide surgery, uses smaller incisions and least invasive method Mini-Open Repair - incision is shorter than open, and uses arthrocopeto assess and treat other stuctures such as the acromion, avoids detaching deltoid, then RC repair is done through incision., Common activities leading to tear Throwing overhead, painting, carpentry ???? Subjective Age- older is indication of degenerative tear MOI/cheif complaint- repetative overhead injury(microtruama), FOOSH (macrotruama), lifting something too heavy with a jerking motion (macrotruama) Pain rating/type/location: pain around the acromialhumeralspace and sometimes down the arm, pain raiting will depend on person, pain is usually a dull ache or if macro truamma a quick intense pain ease pain- limited use, No overhead movements worsen pain- overhead movement, jerking shoulder up, night pain when laying of affected side, sustatined overhead activitiy Red Flag questions- night pain, sudden weight loss, other pt visits, bowel and bladder issues , dizziness, blurred vision, fever, pain unrealated to activity, pain not reduced by rest, smoking Past medical history- history of falls, pervious RC injuries, surgeries, other shoulder issues PFHx- cancer, CV issues, pulmonary issues, imiaging Activity- overhead activity (job or recreational), Interventions (Frequency, Intensity, time, type) HEP - Ice 20 minutes on, at least 2 hours before reapplying - Wear sling during day and while sleeping, except for showering - Starting week three begin passive pendulums, towel press-up, forward bow, towel slide, supine PROM, and scapular protraction with ball on table Week 1 - Gentle supine PROM scaption and ER with elbow at side - Manage pain/inflammation via cryotherapy and/or e-stim - AROM hand, wrist, elbow, and neck - Ball squeezes - Stationary biking or non-treadmill walking with sling on Week 2 - Grade 1 and 2 shoulder joint mobilizations for pain relief and reduce guarding - PROM flexion, extension, abduction, ER, and slight IR - AROM scapular retraction and depression - AROM all cervical motions - Ball squeezes - Manage pain/inflammation via cryotherapy and/or e-stim - Stationary biking or non-treadmill walking with sling on Week 3 - Implement HEP - Small circle pendulums - Isometrics hand, wrist, elbow, and neck - Grade 1 and 2 shoulder joint mobilizations for pain relief - Scapular retraction and depression isometrics - PROM flexion, extension, abduction, ER, and slight IR - Stationary biking or non-treadmill walking with sling on Week 4 - Submax shoulder isometrics in neutral - Isometrics hand, wrist, elbow, and neck - Progress from PROM to AAROM - AAROM supine shoulder flexion with dowel - AAROM standing shoulder ER and easy IR - Grade 1 and 2 shoulder joint mobilizations ???? PT Goals Week 1 - Wound care, edema and pain management, postural awareness, compliance with precautions, use of sling, proper dressing and washing techniques to maintain precautions Week 2 - Same as week 1, including protecting the repair, prevent negative effects of immobilization, and work towards PROM flexion of 100, ER 20, and abduction 60 Week 3 - Same as weeks 1 & 2, including promoting proprioception and scapulo-humeral rhythm, and PROM flexion 130, ER 40, and abduction 75 Week 4 - Same as previous including restoring functional use of the involved extremity, promoting dynamic stability and proprioception, and PROM flexion 140, ER 50, abduction 80, and restoring AROM, Subjective Age- older is indication of degenerative tear MOI/cheif complaint- repetative overhead injury(microtruama), FOOSH (macrotruama), lifting something too heavy with a jerking motion (macrotruama) Pain rating/type/location: pain around the acromialhumeralspace and sometimes down the arm, pain raiting will depend on person, pain is usually a dull ache or if macro truamma a quick intense pain ease pain- limited use, No overhead movements worsen pain- overhead movement, jerking shoulder up, night pain when laying of affected side, sustatined overhead activitiy Red Flag questions- night pain, sudden weight loss, other pt visits, bowel and bladder issues , dizziness, blurred vision, fever, pain unrealated to activity, pain not reduced by rest, smoking Past medical history- history of falls, pervious RC injuries, surgeries, other shoulder issues PFHx- cancer, CV issues, pulmonary issues, imiaging Activity- overhead activity (job or recreational) ???? Signs and symptoms Symptoms- loalized pain in acromialhumeral space, may extend to lateral shoulder or elbow, aggravated by elevation, pain with sustained overhead activites, night pain(laying of affected shoulder) Signs- limited overhead reaching and mobility, stiffness, weakness particularly in abduction and/or extrernal rotation, painful arc, *** if small or partial tear- weak and painful with activation *** if complete tear- weak and painless and unable to elevate shoulder, Subjective Age- older is indication of degenerative tear MOI/cheif complaint- repetative overhead injury(microtruama), FOOSH (macrotruama), lifting something too heavy with a jerking motion (macrotruama) Pain rating/type/location: pain around the acromialhumeralspace and sometimes down the arm, pain raiting will depend on person, pain is usually a dull ache or if macro truamma a quick intense pain ease pain- limited use, No overhead movements worsen pain- overhead movement, jerking shoulder up, night pain when laying of affected side, sustatined overhead activitiy Red Flag questions- night pain, sudden weight loss, other pt visits, bowel and bladder issues , dizziness, blurred vision, fever, pain unrealated to activity, pain not reduced by rest, smoking Past medical history- history of falls, pervious RC injuries, surgeries, other shoulder issues PFHx- cancer, CV issues, pulmonary issues, imiaging Activity- overhead activity (job or recreational) ???? Objective Systems Review: CV, NM, MSK, cognition AROM/PROM, end feels, RI, MMT Joint play assessment Palpation of RC tendons and muscle bellies (as able to) Special tests: -Clinical Prediction Rule for RC tear Painful arc, drop arm sign, infraspinatus MMT -Lateral Jobe -ERLS (infraspinatus and teres minor) and IRLS (subscapularis) -Empty can **Some of these tests also test for subacromial impingment which can stress the RC tendons and lead to a tear, Pathology A tear (partial or full thickness) of one of the four rotator cuff muscles -Subscapularis -Infraspinatus -Teres minor -Supraspinatus ???? Common Comorbitities Diabetes Hypercholestremia