RTC Related Shoulder Pain: Operative Management

- No clinically important difference, but statistically meaningful, between groups

- Main reason behind surgery and placebo having same results is that rest and PT progression is identical

- Second reason is psychological aspect that surgery is the fix (I got what I thought I needed)

what are the key points about the Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW) when comparing surgical decompression with arthroscopy alone (placebo) and no treatment

- RTC related pain without evidence of a full-thickness RTC Tear

- May be performed alongside a RTC repair.

- Pain, weakness interfering with work or ADL's, not responsive to appropriate conservative management

Indications for Subacromial Decompression surgery

- NSAIDs

- Subacromial injections (2-3, 2 months apart)

- Activity modification and rest

- Rehabilitation program to restore movement and strength (at least 12 weeks)

what conservative treatment/management options for RTC related pain or subacromial related pain should be utilized before attempting subacromial decompression surgery

- Largely satisfactory results in majority of cases for open or arthroscopic acromioplasty but results are no better than conservative management or placebo surgery.

- Surgery can be a powerful placebo

- Are the post-surgical relative rest and graduated rehab what lead to the improvement?

Key points about Subacromial decompression Outcomes

Minimal to no post-surgical precautions because nothing was repaired (similar to arthroscopic partial meniscectomy)

What does the Post-Operative PT Management of Subacromial Decompression (SAD) entail

- May be given a sling to wear for comfort in first few days

- Treat similar to an acute/irritable RTC disorder

- ICE

- ROM exercises

- Early strengthening: isometrics

- Manual therapy for pain and mobility (GH joint, AC, thoracic spine)

what are the main component of the acute phase of Post-Operative PT Management of Subacromial Decompression (SAD)

- Graduated RTC strengthening program as you would for a non-operative RTC related disorder

- Program should match the functional demands of the patient

what are the main component of the sub-acute phase of Post-Operative PT Management of Subacromial Decompression (SAD)

- Traumatic full-thickness tear

- Degenerative full-thickness tear with failed rehabilitation (at least 12 weeks)

what are indications for RTC repairs

- Will generally wear a sling for 4-6 weeks post op

- No lifting arm or objects for 6 weeks

- No heavy lifting for at least 12 weeks

- Resuming work around 3 weeks if desk job, at least 12 weeks if manual labor/active job

- Rehabilitation lasts 12-16 weeks

what are general post-op guidelines for RTC repairs

- Older age (> 60)

- Pre-operative RTC strength(<3/5)

- RTC fatty infiltration

- Multiple tendon involvement (2 or more)

- Larger tears associated

Factors predicting lower functional outcomes and lower post-operative cuff integrity following a RTC repair

- Low expectation for efficacy of PT for early transition to surgery, Worker's Compensation and patient activity level for late transition to surgery

- PT successful in 70%+ with symptomatic, atraumatic full-thickness RTC tears

when following the holistic approach after a RTC tear, what is the likely need for surgery down the road

- beginning 72 hours-2 weeks post op

- Early shoulder ROM (Passive only or Active assistive/active)

what does the early rehabilitation timeline entail

- beginning 4-6 weeks post-op

- Same protocol as early just starts later

what does the delayed rehabilitation timeline entail

- protect repair

- decrease pain and inflammation

- gradually increase shoulder ROM

- improve scapular and distal strength + mobility

what are the goals of phase 1 RTC repair guidelines according to the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines

- sling compliance

- no AROM of shoulder

what are precautions associated with phase 1 RTC repair guidelines according to the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines

- normal scapular mobility

- full AROM distal to shoulder

what are the requirements to advance from phase 1 of the RTC repair guidelines according to the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines

- (6-12 weeks)

- Wean from sling

- progressive AROM/AAROM

what are the key points of phase 2 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- protect repair and reduce pain/inflammation

- improve PROM (80-100% of forward elevation and ER)

what are the goals of phase 2 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- no AROM of shoulder

- no maximal cuff activation

what are precautions associated with phase 2 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- activates cuff and deltoid without pain

- tolerates arm out of sling

- ROM 80% or greater

what are the requirements for advancement from phase 2 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- (12+ weeks)

- RTC strengthening

what are the key points of phase 3 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- eliminate pain/inflammation

- restore full PROM

- return to light ADLs <90 deg of elevation

what are the goals of phase 3 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- avoid shoulder shrug

- limit overhead activity

- avoid lifting heavy objects

what are precautions associated with phase 3 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- full PROM

- minimal pain

- normal scapulo-humeral rhythm with shoulder elevation < 90 deg

what are the requirements for advancement from phase 3 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- 5-6 months

- Job or sport specific activities for those that require it*

what are the key points of phase 4 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

avoid overhead activity until proximal stability is obtained

what are precautions associated with phase 4 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- normal scapulo-humeral rhythm throughout full ROM

- 5/5 scapular and shoulder strength

what are the requirements for advancement from phase 4 for the American Society of Shoulder and Elbow Therapists' Arthroscopic RTC Repair Guidelines: Thigpen et al. 2016

- Biceps tendinopathy

- Patients complain about persistent elbow supination/flexion when loaded

- Observed elbow flexion/supination weakness/pain reproduction

- If potential problem just do them together so you have 1 surgery instead of 2

what are indications for a RTC repair with a biceps tenodesis

- AROM of elbow

- Loading

- Sling

- Sleeping position

what are precautions for a RTC repair with a biceps tenodesis

Surgery has not been shown to be more effective than conservative treatment alone

What is the main clinical implication of surgery vs. conservative treatment for RTC tears

No clinically significant difference in Constant score or pain reduction

At 1 year, how does surgery compare with active physiotherapy for RTC tears?

It has fewer complications and is less expensive than surgery

Why is physiotherapy recommended before surgery for RTC tears

Conservative treatment, including active physiotherapy

What is the recommended initial treatment for RTC tears

75% had a favorable outcome at 5 years

What percentage of patients had a favorable outcome after 3 months of nonoperative RTC treatment

They eventually underwent rotator cuff repair

What happened to the other patients after nonoperative RTC treatment

Outcomes were not different between the two groups

How did long-term outcomes compare between conservative treatment and later surgery

RTC-related pain without a full-thickness RTC tear

What is subacromial decompression (SAD) surgery generally used for

The impingement model

What model is the concept of SAD surgery based on

Create more space for the RTC to reduce pain and improve function

What is the goal of subacromial decompression surgery

Part of the acromion, bursa, coracoacromial ligament, and potentially distal clavicle

What structures may be removed during SAD surgery

Arthroscopically

How is SAD surgery generally performed

Pain relief and improved function

What are the main goals of SAD surgery

Outcomes are nearly identical, except the early group has increased ROM at 12 weeks

What are the overall outcomes when comparing early vs. delayed RTC rehabilitation

Pain, function, ROM, and retear rates are the same in both groups

At 1 year, how do early vs. delayed RTC rehabilitation compare

Patients at higher risk for retear, including older patients and those with larger or multiple-tendon tears

Which patients may benefit from delayed RTC rehabilitation

0–6 weeks:

sling for 4–6 weeks and begin PROM at week 2 with gradual ROM progression

What is Phase 1 of RTC repair rehabilitation

4-6 weeks

What is the recommended sling duration after RTC repair

Week 2, with gradual progression in range

When does PROM begin after RTC repair

ER to 30° and flexion in the scapular plane to 100°, with gradual progression

What are the PROM guidelines during Phase 1

6–12 weeks: wean from the sling and progress AROM/AAROM

What is Phase 2 of RTC repair rehabilitation

12+ weeks: begin rotator cuff strengthening

What is Phase 3 of RTC repair rehabilitation

5–6 months: begin job- or sport-specific activities as needed

What is Phase 4 of RTC repair rehabilitation

Improve scapular and shoulder strength to 5/5

Improve neuromuscular control

Normalize scapulohumeral rhythm throughout full ROM.

What are the main goals of Phase 4

Visits should be planned wisely; 3x/week may be unnecessary when treatment is primarily PROM

How should PT visits be planned during Phase 1 after RTC repair

To prevent stiffness and maintain function while the shoulder is immobilized in a sling

Why should adjacent areas remain mobile after RTC repair

Cervical/thoracic spine, scapula, elbow, wrist, and hand

Which adjacent areas should remain functionally mobile

No. Stiffness can occur, especially with prolonged immobilization or delayed rehab

Should you panic if the shoulder becomes stiff after RTC repair

Less is often more; avoid overloading or overcomplicating the program

What is an important principle when choosing rehab exercises

Follow the healing timeline and consider the repair's status before adding resistance

When should you think critically about starting resistance exercises

Around 6 weeks post-op

When do most RTC repair programs begin active motion

Around 12 weeks post-op

When do most RTC repair programs begin strengthening

Protect the repair while gradually restoring mobility, function, and strength

What is the overall goal of post-operative management after RTC repair