The Rotator Cuff Chronicles: Tales of Repair, Resilience and Rehabilitation
Welcome, dear Flathead Valley residents, to a captivating and informative journey into the realm of rotator cuff repairs! I am Tanner Benedict, your local Doctor of Physical Therapy (DPT), and it is my utmost delight to be your guide through this remarkable tale of repair, resilience, and rehabilitation. So, settle into the cozy comfort of your favorite La-Z-Boy chair and prepare to immerse yourself in the enthralling world of rotator cuff repairs!
Once Upon a Tear: The Origin Story of Rotator Cuff Injuries:
In the complicated world of shoulders, where bones, ligaments, muscles and tendons sway to the rhythm of human movement, the noble rotator cuff stands as a knight in shining armor. But alas, the knight is not without a formidable fight. Let's discover the origin story of rotator cuff injuries, from traumatic incidents to wear and tear over time and how these injuries can disrupt the functionality of the shoulder and leave our heroes in need of repair.
To better understand injury to the rotator cuff we first must understand the anatomy. The rotator cuff is comprised of four separate muscles. These muscles (Supraspinatus, Infraspinatus, Teres Minor and Subscapularis) work together to stabilize the glenohumeral (Shoulder) joint via force coupling mechanisms and allow for the shoulder to move throughout three planes of motion (Sagittal, Frontal and Transverse). The force coupling mechanism functions when two or more muscles work together in parallel to each other in opposite directions and produce a force (magnitude) that is equivalent to the other.
Think of this like a tug of war match with your best friend (I know you're stronger, but for this example you're equal strength). At the middle of the rope a pulley exists with resistance, but the pulley has two different grooves one for your rope and the other for your friend's. When you both pull on the pulley it will rotate around a rod and the resistance will equally be pulled by you and your friend (jokes on you, you're fighting the pulley, not your friend). For the shoulder, this concept is incredibly important to allow for movement as well as stability. The glenohumeral joint (Ball and Socket) requires balanced forces to allow the humeral head (Ball) to slide and glide within the glenoid fossa (Socket). The mechanism allows the humeral head to stay in the correct alignment while moving the upper extremities through the plane of movement. When this pattern is disrupted, we begin to cause accessory motion within the joint resulting in increased stresses being placed on the directly associated structures (Rotator cuff) as well as surrounding joints and musculature like the neck, shoulder blade and mid back (Cervical spine, Scapulothoracic joint and Thoracic spine for example). Over time these structures will undergo increased forces which they're not built to accommodate, thus leading to failure at variable levels of injury. When discussing injury to the rotator cuff a grading system is used (Grade 0,1,2,3,4). Grade 0 is representative of a normal and healthy rotator cuff, Grade 1 displays superficial fraying (<1 cm), Grade 2 displays fraying of a larger size (1-2 cm), Grade 3 is considered a level of tissue disruption (2-3 cm) and Grade 4 is considered a substantial tear and involves multiple tendons of the rotator cuff. Based on the grade of tear, patient presentation and orthopedic evaluation, a plan of care can be created to involve physical therapy or orthopedic surgery to correct the injury.
The Surgeon's Quest: The Anatomy of Rotator Cuff Repairs:
Bright lights, gowns, masks and gloves, welcome to the operating room, where skilled surgeons and support staff don their capes and wield their scalpel-wielding swords. In this chapter, we'll explore the intricacies of rotator cuff repairs. From open surgeries to minimally invasive techniques, witness the surgeon's quest to mend the damaged tendons and restore stability to the shoulder joint.
Rotator cuff repairs in the United States were estimated to account for 400,00 to 500,000 surgical interventions and will continue to increase based on population changes as described by Dr. Andrew Green, an orthopedic surgeon with the Lifespan Orthopedics Institute and professor/chief of the division of shoulder and elbow surgery at the Warren Alpert Medical School of Brown University in his article "Rotator Cuff, Shoulder Pain and Injuries", December 8, 2020. Within this population three techniques are most commonly used across the United States (Open repair, Arthroscopic repair and Mini-open repair). The repair format will depend on several factors including grade level of tear, the quality of tissue that remains, the patient's overall anatomy and the orthopedic surgeons experience and training. In the end of the day, the orthopedic surgeon will select the surgical intervention that gives the patient the best repair and recovery possible based on the previously listed variables. For more specific information regarding surgery, it is crucial to contact your local orthopedic surgeon and support staff to answer your questions specific to you.
The Road to Recovery: Rehabilitation Strategies for Rotator Cuff Repairs:
As our brave heroes rise again from the operating room, a new chapter begins— rehabilitation. Join me on a journey through rehab, where physical therapists become the guides and mentors (I like the idea of being Gandolf) of healing. We'll dissect the various surgical protocol stages, from day one to one year, and develop knowledge of regaining strength, mobility, and function. Discover the wonders of therapeutic exercises and activities, manual techniques, and movement pattern correction that help our heroes regain their glorious armor and the sharpened steel.
Rotator cuff repair rehabilitation follows specific orthopedic protocols to allow for proper tissue healing, reducing reinjury rates and allowing for the repair to be appropriately progressed over a time frame of roughly six months (This number is not concrete, but serves as a guideline).
From surgical intervention to the first six weeks of rehab the primary focus is to protect the repair and promote the correct healing process. Within these six weeks immobilization by some variation of sling or immobilizer is standard practice. Primary precautions within this phase are typically to avoid all active range of motion (AROM) with the surgically repaired upper extremity. Physical therapy within this time frame will normally consist of education on posture, plan of care and precautions as well as implement pain reducing techniques and the initiation of passive range of motion (PROM) if allowed within the protocol. Remember, this is not a one size fits all concept and will depend on the orthopedic surgeon's protocol, so always ask your surgeon and physical therapist for specifics regarding you.
Weeks 6-12 rehab will begin to transition allowing for more freedom (discontinued use of sling or immobilizer) and a slow progression from PROM to AROM as the patient is able. Other techniques will be used to improve joint mobility (mobilization techniques), increase ROM and strength with home exercise program activities (HEP) and to begin progressing from rotator cuff isometrics (using the muscle, but not moving the arm) to low level resistive movement.
Weeks 12-20 are primarily focused on restoration of complete and functional AROM, progression of strength-based programing and movement pattern correction.
Weeks 20 on are focused on return to activity over a gradual process including return to work, recreation or sport.
Follow the link below to see a great example of a rotator cuff repair from the Boston Shoulder Institue.
Facing the Trials: Common Challenges During Rotator Cuff Rehabilitation:
The path to recovery is not without its tribulations! Along the path, our heroes may face trials such as pain, lost sleep, stiffness, frustration and reduced function with daily activity and recreation. Rest assured and calm your fears for now we'll navigate through these challenges and arm ourselves with strategies to overcome and combat these nasty foes. From pain management techniques to addressing faulty movement patterns of the shoulder we'll ensure our heroes reclaim their glory in their battle for shoulder rehabilitation.
For most patients their first trial comes in the form of fabric, Velcro and a weird, shaped pillow under their arm (the sweat collector). The sling/immobilizer functions to help maintain a neutral alignment of the shoulder during the important acute phase of recovery and is crucial for proper healing and protection of the repair. The primary pitfall of sling use is improper fitting or incorrect use. For most, the sling should allow the elbow to be near a 90-degree angle with the shoulder feeling supported, but not stuffy. The next component is to make sure the sling strap is distributing forces into the opposite shoulder without placing too much force on the neck again as the shoulder is resting in a neutral alignment. When these corrections fail, rely on your arsenal of other fabrics or materials to adjust the position of the arm to reduce rubbing and or areas of annoyance. ***If you are experiencing issues with your sling, ask your therapist for ideas, remember they want you to succeed in this journey!
Second, the vague term of "pain management" enters the battlefield. For most, pain will be a part of the process, but don't worry your skilled physical therapist will help guide you through this process with several tools. In the acute phases posture and proper use of pillows for support are key. Focusing on these two variables can make a world of difference in reducing pain and allowing for finding positions of comfort. Each patient is different and will require different tactics. The second part of pain management shows its head in the form of beginning to move the arm with manual techniques and PROM activities (guided stretching completed by your physical therapist). For most, this phase initially will stir up some apprehension, but most respond very well and will comment that the shoulder has reduced pain after using these techniques. I tend to use the term "motion is the lotion" quite a bit in early phases of rehab to reiterate the point that the human body is intended to move and experience forces (positive therapeutic ones, not lifting your 32 oz iced mocha capa latte atta. Side note, I love coffee and respect the wonders of caffeine).
Third, as the shoulder begins to develop strength and improve ROM, we tend to display old faulty movement patterns. Movement patterns of the shoulder are incredibly complex due to a free-floating shoulder blade (scapula), the shoulder joint (glenohumeral joint) and the foundation of it all, the middle back (thoracic spine). To solve the movement issue, it more than likely will take corrective techniques to all these areas whether they need to improve mobility, increase stability or correct motor control (how are brain activates and uses muscles that control these regions). The topic of movement pattern correction can be discussed in great detail, but for the sake of the blog I will keep it quick and simple. Well use lifting the shoulder overhead (flexion) as our example. For the arm to move overhead the middle back needs to be mobile enough to extend (flatten) while the shoulder blade rotates up and around the rib cage (roughly 60 degrees) allowing the ball and socket to only travel through as much ROM as needed (roughly 120 degrees). If at any point throughout this movement one area is not sufficiently working, another area will take the stress increasing the risk of injury and reduced function (ROM or strength). At this point a skilled set of eyes and hands will save the day and find the solution to the problem that is being presented. Each individual will have different patterns and limitations, which further places the importance on trusting your skilled physical therapist to guide you through the process.
The Long-Term Legacy: Maintaining Shoulder Health Beyond Repair:
As we approach the end of our fantasy adventure, The Rotator Cuff Chronicles: Tales of Repair, Resilience and Rehabilitation, we must address the long-term demands and needed compliance of having a positive rotator cuff repair story. We'll discuss the importance of ongoing shoulder maintenance (COMPLIANCE, COMPLIANCE, COMPLIANCE), injury prevention strategies, and lifestyle modifications to promote a resilient repair for the years that follow. If I can stand on the roof and scream, I hope you can hear me, this is one of the most important parts of the adventure, the dedication to continual work on your shoulder to maintain the repair for work, activities of daily living and recreation.
Maintaining shoulder health after a surgical repair involves a comprehensive approach that combines physical therapy, lifestyle modifications, and regular exercise. Physical therapy plays a pivotal role in restoring strength and mobility, helping individuals return to their usual activities. Engaging in low-impact exercises like swimming or yoga can enhance flexibility, improve posture, and strengthen the surrounding muscles, reducing the risk of re-injury. Lifestyle modifications, including maintaining a healthy weight and fostering good sleeping habits, can also contribute to long-term shoulder health. Furthermore, it's crucial to heed your body's signals and avoid overuse, allowing ample recovery time between strenuous activities.
Conclusion: Dear readers, we have reached the final chapter of our grand tale—the world of rotator cuff repairs. As the saga of the Rotator Cuff Chronicles concludes, it's clear that preventative measures, early diagnosis, and a carefully managed recovery process play a crucial role in successfully dealing with rotator cuff injuries. This journey has been a testament to human resilience, the power of medical science, and the importance of an integrated approach to health and wellbeing. It underscores the message that, while such injuries can be daunting, they are not insurmountable with the right mindset, support network, and professional guidance.