Rotator Cuff Labral Pathology

Rotator Cuff and Labral
Pathology: Post-Operative
Considerations and
Rehabilitation Implementation
By Leonard Macrina MSPT, SCS, CSCS
Course Materials
Post-operative Rehabilitation
Following Common Shoulder
Arthroscopic Procedures
Leonard C. Macrina MSPT, SCS, CSCS

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation
Leonard Macrina, MSPT, SCS, CSCS
Course Objectives
Demonstrate an understanding of the involved anatomy.
Recognize the pathomechanics of various shoulder injuries
and possible tissue injury.
Perform and interpret specific clinical examination tests &
maneuvers for the shoulder.
Outline a scientifically based post-operative rehabilitation
protocol for each glenohumeral lesion, particularly following a
repair procedure
Post-op Guidelines
Rehabilitation program must match surgery
Gradually restore ROM
Good understanding of the tissues involved

Communication between MD and PT is critical
Continually assess and adjust based on patient
progress
Pain
End feel
strength
Favorable outcomes expected

Arthroscopic Repair of:

Labral lesions
SLAP II in particular
Rotator Cuff Repair

Anterior Bankart Repair
Glenoid Labral Lesions

Introduction
Common injury difficult to diagnose

May occur in isolation or
concomitantly
SLAP lesions: Snyder et al:
Arthroscopy 90 Andrews:
AJSM 85
Difficult to diagnose
subtle symptoms, pain, popping
can cause disability
prolonged symptoms
Anatomy
Narrow, wedge shaped structure
Surrounds periphery of the glenoid
Intimately attached to capsule
Expect in the anterosuperior aspect
Important structure for normal
asymptomatic shoulder function
Consists of mainly fibro-cartilaginous tissues
Bost & Inman JBJS: 42
Codman, The Shoulder: 34
DePalma, AAOS : 49
Grays Anatomy : 88
THE GLENOID LABRUM

Vascularity
Originates from suprascapular,

circumflex scapular branch of
subscapular, & posterior
circumflex humeral
Mainly peripheral blood supply
Superior & anterosuperior less
vascularity
Vascularity decreases with age
Neural Anatomy
No mechanoreceptors in
labrum
Free nerve endings in fibrocartilagous tissue of labrum
and connective tissue
surrounding the labrum
Vangsness: Arthroscopy 1998
GLENOID LABRUM FUNCTION

Enhances Static Stabilizers
Acts as chock block

Attachment site of capsule
Capsulolabral complex to
glenoid
- when disrupted there is
instability
GLENOID LABRUM
Normal Variants
Buford Complex
Cordlike middle glenohumeral
ligament attaching to the base
of the biceps anchor
Absence of labral tissue on the
anterior superior glenoid
Attachment of MGHL SLAP
repair will markedly decrease
rotation!
Buford complex: 1.5-5%

GLENOID LABRUM
Normal VariantsSublabral foramen
Incidence in shoulder
arthroscopies:
Sublabral foramen: 12.0% (73%
in MR and cadaver studies)
Normal variants may become
pathologic lesions!
Do not stabilize normal
structures!
Mechanisms of SLAP Lesions

Traumatic Lesions
Fall onto outstretched arms

Forceful abduction diving
(diving)
Weightlifters
Pushing heavy objects

Common in offensive linemen
Blow to the shoulder

Glenoid Labral Tears

SLAP Lesions
Type I:
Superior labrum frayed
Snyder: Arthroscopy, 1990

SLAP Lesions
Type II:
Superior labrum
detached & frayed
Snyder:Arthroscopy 90

SLAP Lesions
Type III:
Bucket handle tear,
displaces into joint
Snyder: Arthroscopy 90

SLAP Lesions
Type IV:
Bucket handle tear
displaces, biceps also
subluxes into joint
Snyder: Arthroscopy 90

SLAP Lesions
Type II peel back

mechanism
Torsional force of biceps
labrum as arm abducts &
ER
Change in biceps vectors
from anterior horizontal to
vertical & posterior ???
American Sports Medicine Institute

ASMI.org
VIDEO

Traumatic Lesions
Repetitive stresses during throwing
(microtraumatic)
Anterosuperior lesion, near biceps
During follow-through phase

*Arthroscopy of 73 throwers 83%
exhibited a Labral lesion Andrews,
AJSM 85
*Throwers undergoing TCS: 91%
labral pathology
Wilk,Reinold,Andrews:JOSPT 02
Miniaci et al:AJSM 02
Examined 14 asymptomatic
professional pitchers
Performed MRI & clinical
examination
79% exhibited abnormal
glenoid labrum
79% exhibited changes of the
supraspinatus tendon
Humeral head changes were
seen in 36% (cystic changes)

Degenerative Changes
Due to shoulder mobility and poor

blood supply
Repetitive stresses lead to tears
Significant degenerative labral
tears in older individuals
Kohn, Arthroscopy 87
106 autopsy specimens
84% degenerative labral lesions
50% exhibited detachment
Clinical implications ???
Maffett et al: AJSM 95

Mechanisms of Injury:
Fall onto shoulder

Fall onto outstretched arm
Lifting overhead
Gradual repetitive lifting
Traumatic dislocation
Traction force
Abduction & ER
MVA
Insideous
15%
8%
13%
6%
13%
12%
8%
6%
9%
Type V:
An anterior-inferior
Bankart lesion
continues superiorly to
include separation of
the biceps tendon
Maffet: AJSM 95
360 Type
Avulsion of the glenoid labrum

around the entire glenoid
often traumatic mechanism
Noticed increased incidence

recently
New protocol

Clinical Examination
Clinical examination
History
Physical examination
Specific tests
MRI (enhanced)
Correlate the information
Goal is to make the accurate &
appropriate clinical diagnosis !
SLAP testing
Compression Rotation (Grind)

Clunk test
Biceps load
Pronated load
Resisted supination with ER
Crank
SLAP LESIONS
Evaluation
Subjective history
May describe single trauma
Fall or during throwing
Complaint of pain
Popping, clicking, catching
Is clicking + for SLAP lesion ?
Deep pain within the joint
Pain with specific movement
Mechanical pain
Inability to perform sport at high level

SLAP Tests
Physical examination
PROM & AROM, painful arc of motion
Special tests:
Active compression OBrien: AJSM 98

Compression rotation Snyder: Arthro 90
Speeds test
Apprehension sign Snyder 40%
Grind test Wilk: JOSPT 98
Crank test Liu: AJSM 96
Clunk test Andrews: AJSM 85
Anterior Slide test Kibler: Arthroscopy 95
Biceps Load test Kim: AJSM 99
Test
Active Compression (18)
Anterior Slide (24)
Anterior Slide (30)
Biceps Load II (25)
Compression Rotation (30)
Crank (18)
Crank (28)
Crank (35)
Crank (52)
MRI (5)
MRI (8)
MR (52)
Pain Provocation (32)
Resisted Supination ER (35)
Speeds (18)
Speeds (21)
* Positive Predictive Value
** Negative Predictive Value
N
33
426
318
37
65
226
426
127
426
33
62
36
65
52
46
65
32
40
33
50
Sen.
54
47
100
78
54
78
8
90
24
39
91
35
46
89
89
42
100
83
9
32
Spec.
47
55
99.5
11
31
92
84
97
76
67
93
70
56
91
88
92
90
82
74
75
PPV*
55
10
94.6
70
34
NPV**
45
91
100
14
50
5
92
9
59
94
75
41
90
89
63
97
92
30
50
90
96
90
47
90
29
61
83
64
40
58
Wilk et al: JOSPT 05
GLENOID LABRAL LESIONS

Active Compression Test
OBrien et al, AJSM 1998
Differentiate labral lesions
and AC joint abnormalities
Empty can position, thumb

down vs. thumb up
Positive test: pain with
pronation / extension
Sensitivity 100%, specificity
95%

Evaluation
Clinical examination history
Variety of historical features
Pain with overhead movements
Popping, catching,locking, grinding 50% of
patients (Synder: JSES 95)
History of sudden traction

Overhead athletes change traction
Compression fall onto outstretched arm
SLAP LESIONS
Evaluation
Subjective history
Chief Complaint:
Pain
Aching
Loss of strength
Loss of motion
Going out
Stiffness
Weakness
93%
21%
18%
52%
18%
33%
31%
SLAP LESIONS
Evaluation
Subjective history
Chief Complaint: PAIN
Pain Magnitude:
Slight pain: 1%
Only after activity 10%
Only during specific activity 99%
Moderate pain: 51%
Marked Pain: 49%
Complete disability: 3%
SLAP Lesions
Surgical Treatment
Type I: Debride back to stable rim
Type II: Reattach superior labrum to glenoid,
stabilize biceps anchor
Type III: Torn fragment resected, leave
remaining stable tissue
Type IV: Treatment base on extent of biceps
tear
Less than 30%: torn tissue
resected
Greater than 30%: biceps repair (age)
Type II SLAP Before Repair

Type II SLAP After Repair

SLAP Lesions
Rehabilitation Guidelines
JOSPT May 2005
SLAP Lesions
Rehab Guidelines
Rehabilitation must match the surgery
Repair vs. Debridement
Based on type of lesion
SLAP classification I thru IV
Emphasis on dynamic stabilization

Do not overstress healing tissue
Minimize biceps activity (II, IV)
Microtrauma injury
*think dynamic stabilization !!!
Rehab Following SLAP Repair with Concomitant

Surgical Procedures
SLAP repair with stabilization surgery
Thermal capsular shrinkage
Bankart repair (type V)
Capsular shift or plication
SLAP repair with cuff repair

Arthroscopic or open repair
SLAP repair with decompression

SLAP with debridement
Rehabilitation Following
SLAP Repair
Overview
Concern is to control forces/loads on

repaired labrum
ER/IR motion usually Not a problem
no excessive motion for 8 wks*
Restoration of full arm elevation
(flexion) sometimes difficult
Determine extent of lesion*
Number of suture anchors used
Location of lesion
Ensure dynamic stability is present

SLAP Repair
Precautions
Control forces for 6-8 weeks

No overhead movements (above
90) for 3-4 weeks
Need stable glenohumeral joint
Emphasize dynamic joint stability
Minimize GH translation
No isolated biceps 8 weeks

No heavy lifting
SLAP Repair
Precautions
No CKC exercise drills until 8

weeks post-op
No resisted movements
above 90 degrees elevation
for 8 weeks
No heavy bench press, heavy
lifting overhead until 3
months post-operative
SLAP Repair
Weeks 1-3
Sling for 3-4 weeks

Sleep immobilizer 4 weeks
Immediate limited motion

AAROM / PROM flexion to 700
Weeks 2-4: flexion to 90
AAROM ER/IR in scapular plane

~ 300 Abduction
Isometrics (all planes)

No isolated Biceps
Isotonics week 2 (active ROM )

SLAP Repair
Weeks 3-4
Remove ROM restrictions

Gradually increase ROM
Flexion to tolerance
ER/IR at 900 ABD
Full ROM @ week 7-8

ER @90 abd to 95-105
in overhead athletes
Progress isotonic strengthening program

throwers ten program
Why is the Rotator Cuff Important?

Dynamic stabilizers
Rotator Cuff
Center humeral head into
concave glenoid fossa during
upper extremity motions
Vital in arthrokinematics
Appropriate muscle strength
and balance
Pathology results in inefficiency
Rehabilitation Following SLAP Repair

Full ROM by week 6-9
ER to 900 by week 6-7
ER to 1050 by week 7-8
ER to 115 at week 10-12
Plyometrics week 8
2 hand plyos week 8-10
1 hand plyos week 12
No CKC drills for 8-10 weeks

Isolated biceps: initiate week 8
Light & progress
Machine weights
Week 12
Intermediate Phase
OK to initiate AROM activities ~6 weeks
ER/IR tubing at 0 abduction
Scapula strengthening
Prone rowing
Prone extension
Scapula retractors
Scapula depressors
Continue with rhythmic stabilization

drills
Caution against long lever arm motions!!
Macrina
Advanced Phase
Week 12-16
Goals:
Maintain ROM/flexibility
Progress strengthening
Gradual application of
functional loads
Gradual return to full
activities
2-handed Plyos
One handed plyos...
Return to Activity Phase

Continue strengthening exercises
Initiate interval throwing program (ITP)
Quarterback
Reinold et al JOSPT 2002
Return to competition ~6 months

Contact sports
Rehabilitation following rotator cuff repair

Introduction
Common pathology in orthopaedic
setting
Functionally debilitating
Common mechanism
Traumatic
Traumatic with underlying tissue
weakness
Gradual onset due to weakening,
overuse
Overhead athletes
Spectrum ranges from pitchers to
position players
Generally very different in onset
Clinical Presentation
Symptomatic complaints with
active elevation
Resting or night pain
Pain with resisted ER and/or
elevation
Feeling of dead arm
Pain with late cocking follow
thru
Traumatic dislocation
Differential Diagnosis
Impingement syndrome
Bursitis
C-spine involvement
Frozen shoulder
Labral pathology
Rotator cuff testing
Hawkins/Kennedy
Neers
Active elevation
Passive IR with
elevation
Internal
impingement sign
With reposition test
Empty can
Full can
Drop arm
Lag sign
Lift off
Belly press
Empty can
Full can
Drop arm
Lag sign
Lift off
Belly press
Empty can
Full can
Drop arm
Lag sign
Lift off
Belly press
Empty can
Full can
Drop arm
Lag sign
Lift off
Belly press
Empty can
Full can
Drop arm
Lag sign
Lift off
Belly press
Empty can
Full can
Drop arm
Lag sign
Lift off
Belly press
More likely to detect
tear in upper fibers
Tokish JSES 2003
How accurate are MRIs?

Sher et al JBJS Am 1995
MRI on 96 asymptomatic shoulders
Overall, 33 with RTC tears (34%)
14 full thickness (15%)
19 partial thickness (20%)
If >60 yrs. old

54% had abnormal MRI
If 40-60 yrs. old

28% had abnormal MRI
Why so significant?
Biomechanics and Implementation of

Shoulder Rehabilitation
Dynamic stabilizers
RTC
Center humeral head into
concave glenoid fossa during
upper extremity motions
Vital in arthrokinematics
Appropriate muscle strength
and balance
Pathology results in
inefficiency

Morrey, Itoi et al (1998
Rockwood & Matsen)
Deltoids produced
superior force vector
0-90 but compressive
120-150
SS- consistent
compressive force
throughout full ROM
Post-op considerations
7 Key factors
1. Type of repair
Arthroscopic vs. mini-open
2. Concomitant procedures
3.
4.
5.
6.
7.
SLAP repair
SAD
Capsular involvement
Size of tear
Tissue quality
Age of patient
Length of time from surgery
Ultimate functional goals
Positional player
Starter or reliever
Post-op RTC repair

Keys to treatment
Re-establish capsular mobility
Inferior and anterior capsule
Re-establish humeral head control

(dynamic stability)
Good muscular balance
ER/IR ratio
Do not work through shrug
Post-op keys
Create movement environment
immediately!!
Pulleys
L-bar
PROM
Pendulums
Joint mobs
Prevent excessive scarring, capsular

restrictions
Communication with physician is

critical for successful outcome!!
Post-op issues
Surgical & rehabilitation
Infection
Poor capsular mobility
Spasm or hard end-feel
Significant pain
Over-aggressive
Too early AROM or strengthening
Retear the repair
Unable to return to previous level of function
Classification
Small
Medium
Large
Massive
< 1cm
1-3 cm
3-5 cm
> 5 cm
Protocols
We use 3 types of protocols
Type I: small tear with excellent tissue quality
Type II: medium to large tear with good
tissue
Type III: large to massive tear with poor
tissue
The rehabilitation must match the surgical procedure!!
Overhead Athlete
More aggressive
Younger patient
Greater healing potential
Better tissue quality
Functionally demanding
outcomes
Trend toward
arthroscopic approach
Overhead Athlete
Arthroscopic vs. Mini-open
approach
Minimize tissue involvement
Deltoid sparing
Decreased scar tissue formation

Decreased pain
Similar fixation strength with
improved technology
Trend toward all arthroscopic
repair
Nearly 100% in overhead athlete
Functional Outcomes
Mazzoue, Andrews AJSM
2006
16 professional baseball
players
Full thickness RTC tear
Mini-open approach
12 pitchers, 4 position
Only 1 pitcher (8%)
returned to competition
Risk factors for recurrent tears

Size of Tear
Ide: Arthroscopy 05
Sugaya: JBJS 07- 40% retear rate
Verma: Arthroscopy 06
Age of Patient
Boileau: JBJS 05- 29% failure rate

Liem: JBJS 07
Lichtenberg: Knee Surg Spts 06
Cho: Clin Orthop Surg 2009- 22.5% retear rate
Occupation
Gazielly: Rev Chir Orthop Repar 95
Tissue Quality, early activities, too aggressive

Cho et al 2009
Healing rates
<50 years of age (49
shoulders)
87.8%
51-60 years of age (68
shoulders)
79.4%
>61 years of age (52
shoulders, p = 0.049)
65.4%
small-sized tears (30

shoulders)
96.7%
medium-sized tears (71
shoulders)
87.3%
large-sized or massive tears
(68 shoulders
58.8%
Outcomes
Jones & Savoie Arthroscopy 2003
60 patients with large or massive tears
37 large
Average follow-up 32 months

88% with good or excellent results
No difference in outcomes of massive vs. large
tears
Outcomes
Bennett WF
Arthroscopy 2003
24 full thickness supraspinatus tears only
Small to medium size tears
Improved ASES score from 29 (pre-op) to 82
(post-op)
Outcomes
Cho et al 2009
169 consecutive aRTC repairs
Mean age 57.6 y.o.a
Mean f/u 39.6 months
Per MRI- RTC completely healed in 77.5%

of shoulders
Outcomes
Youm et al JSES 2005
84 patients underwent RTC repair surgery
42 arthroscopic repairs (21 small, 9 medium)
42 mini-open (17 small, 23 medium)
Average follow-up 36 months (range 24-70
months)
No significant difference in outcomes between
2 surgery types
Outcomes measured VAS pain and functional
improvement
Morse et al
AJSM Sept. 2008
Meta-analysis
Arthroscopic vs. mini-open RTC repair
5 studies met inclusion criteria
Level III evidence or better
Minimum 1 year f/u
Validated functional scores (ASES, Constant, UCLA,
SST)
No difference in functional outcomes or

complications between 2 procedures
Arthroscopic Type II
Immediate post-op phase
Re-establish full PROM
Diminish pain/inflammation
Minimize atrophy
Do not over-stress healing
tissues!
Protect healing tissues
Abduction pillow for 4 weeks
Immobilization
Best position for Immobilization??

Hatakeyama et al AJSM 2001
Strain on RTC repair in various positions
0, 15, 30, 45 elevation in coronal, sagittal,
scapula plane
Also from 60 int. rotation to 60 ext. rotation
Scapula Plane
Results
Hatakeyama et al
AJSM 2001
Coronal Plane
Sagittal Plane
Post-operative Phase
Week 1
Sling or abduction pillow
PROM
ER/IR in scapula plane
flexion to tolerance
Pendulums
Pulleys in scapula plane
ER/IR AAROM with L-bar
Submaximal, gentle
isometrics with NMES
Cryotherapy

EMG of supraspinatus during PROM &
AAROM activities
Dockery et al Orthopedics 1998
10 healthy subjects
MVIC supraspinatus during common post-op
activities
PROM elevation <5% MVIC
L-bar flexion 8.3% MVIC
Pulleys 17.6% MVIC
Park, Idjadi, ElAttrache et al

AJSM 2008
Biomechanical testing of 6 cadaveric RTC
Repairs
Compared suture bridge technique to
double row repair technique
Cyclically loaded from 0 to 60 N
Constructs loaded to failure
Also, compared neutral to ER (0-30) PROM

Suture bridge technique significantly
stronger 161N to 135N
ER produced increase tension anterior
supraspinatus relaxed posterior aspect
of supraspinatus

We believe its safe to initiate PROM &

AAROM activities immediately following RTC
repair surgeries
NMES following RTC repair
(Reinold, Macrina, Wilk et al)
AJSM Dec. 2008
39 subjects (mean age 50 years
old)
2 mini open & 37 scopes
Average size of repair was 2.8 cm
Significantly greater force
production with NMES than
without (3.27 kg vs. 2.49 kg)
Post-operative phase
Week 2-4
Continue PROM to tolerance
Pulleys in scapula plane
Initiate AAROM flexion with
L-bar
Full PROM by week 4
ER to 90 week 4
Continue isometrics with
NMES
Re-establish dynamic stabilization
Isometrics with NMES
Rhythmic stabilization drills
Supine 45 abduction
Supine 100 flexion, 20 horiz. abd.
Remember muscle force vectors
Deltoid will assist in humeral head compression above
100 flexion
Rhythmic Stabilization
Intermediate Phase
Weeks 4-8
Goals:
Maintain full PROM

Protect healing tissue
Establish dynamic stability
Re-establish muscular
balance
Re-establish balanced
capsular mobility
activities
Minimize pain
Intermediate Phase
Continue with ROM
PROM, AAROM AROM
ER at 90 abduction to
110-120
IR at 90 abduction to 60
Post-operative phase
Weeks 4-6
Gradual progression in
strength
Initiate ER/IR tubing with
NMES
Initiate scapula
strengthening
Continue isometrics
Must obtain full PROM

Gentle joint mobs as
needed
Intermediate Phase
OK to initiate AROM activities ~6 weeks
ER/IR tubing at 0 abduction
Scapula strengthening
Prone rowing
Prone extension
Scapula retractors
Scapula depressors
Continue with rhythmic stabilization

drills
Caution against long lever arm motions!!
Gravity minimized flexion
Intermediate Phase
Week 6-10
ER at 90 abduction to ~115-120
Progress to Throwers Ten exercises
Stabilization exercises
Wall push-ups
Wall stabs
Emphasis on manual resistance,

endurance with eventual eccentrics
Wall stabilization drills
Manual resistance
Advanced Phase
Week 10-16
Goals: maintain repair integrity
Gradually increase strength
Initiate light functional activities
Stress the tissue
Advanced Phase
Continue Throwers Ten program
Progress 1 lb every 7-10 days
Initiate plyometric activities

2-hand @ week 12-14
1-handed week 14-16
Initiate interval hitting program for position

players
2-handed Plyos
One handed plyos...

Week 16-22
Goals:
Maintain ROM/flexibility
Gradual application of
functional loads
Gradual return to full
activities

Continue Throwers Ten exercises
Initiate interval throwing program (ITP)
Reinold et al JOSPT 2002
Phase I ~16-20 weeks
Phase II ~24-26 weeks
Return to competition ~8-12 months
Rehabilitation following Shoulder

Stabilization procedures
Introduction
Very common in outpatient rehabilitation

Often treated without surgery with good
results
Return to prior function without limits
Dependent on many factors
Surgical intervention warranted if
continued limits in function and/or stability
Rehabilitation must match surgical
procedure
Shoulder Instability
Various types
Acute
Anterior
posterior
MDI
Congenital
Acquired laxity
Due to repetitive stresses
Overhead athlete
Micro-instability
Internal impingement
Key Factors
Direction of instability
Anterior
Most common (98%)
Bankart Lesion
HAGL lesion
Humeral avulsion IGHL complex
Micro-instability
Posterior (~2%)
Football lineman
FOOSH
Mair AJSM 1998
8/9 posterior episodes were offensive
lineman
75% required surgical stabilization
MDI
Congenital laxity
Non-op Instability
Wilk, Macrina NAJSPT Feb. 2006
1.
2.
3.
4.
5.
6.
7.
Onset
Degree
Frequency
Direction
Other tissues involved
NM control status
Functional goals
Immobilization
Acquired- almost never
Traumatic- older patients, sometimes
No long term benefits from immobilization
Hovelius JBJS 1987
Kiviluoto Acta Orthop Scand 1980
Protect healing tissue

Allow scar formation
Immobilization
In what position?
Itoi et al JBJS 2002

Itoi et al JSES 2003
Improved capsular healing and 0%

recurrence rate at 30 ER
Immobilization
Factors that affect re-dislocation rates
Age
Hovelius JBJS 1996
20 years or younger- 85% recurrence rate
40 years or older- 15% recurrence rate
Activity level
Recurrence
Within 2 years
Key Factors
NM control
Motor reaction to sensory input
Detect joint position in space with motor response
to assist in dynamic humeral head stabilization
Lephart JSES 1994
Wilk JOSPT 1997
Particularly at end range

Poor NM control- excessive HH migration
Injury results
Key factors
NM control
Lephart JSES 1994
Compared ability to detect PROM and active joint
reposition
Normal
Unstable
Surgically repaired
Diminished proprioception in unstable shoulder

compared to other 2 groups
Key Factors
NM control
Smith & Brunoli Phys Ther
1989
Significant decrease in
proprioception following
dislocation
Zuckerman JSES 1999

Diminished proprioception
with age
Definitions
Laxity
Assessment of joint displacement
Large range of translation
Allows for functional activities
Instability
Excessive joint translation impedes patient from
performing functional activities
Sports
ADLs
Etc
Onset of instability
Acute
Traumatic
fall onto outstretched
hand
Football lineman
Posterior instability
Excessive horizontal
abduction
Esp. with external
rotation
Dont stretch a patient

with underlying congential laxity
Shoulder Instability
Decision Making
History
Physical Examination
Radiographs
CT/MRI
Diagnosis
1st Time Dx
In/Out Season?
Patient at Risk
EUA/Arthroscopic Findings
Operative Strategy/Priority
1st Priority: LABRUM
2nd Priority: Capsule
3rd Priority: Rotator

Interval
Surgical options
Bankart Repair
Open
Arthroscopic
Anterior
Posterior
Capsular shift
Plication
Laterjet procedure
Thermal capsular shrinkage
Not as common
Capsular Suture Plication

Anterior
Posterior
Both
Laterjet/Bristow Technique
Shoulder Surgery
Position
Beach Chair
Lateral Decubitus
Concomitant procedures
Rotator cuff repair
Rotator cuff
debridement
SLAP repair
Subacromial
decompression
Labral debridement
Rehabilitation Following Shoulder

Stabilization
Rehab Philosophy
Understand type & nature of lesion

traumatic
congenital
Understand type of surgical procedure
Rehab must match the surgery & patient*
Isolated Lesion
Concomitant lesion
Evaluate/grade patients tissue status
Never overstress healing tissue
**Assess end feel**

Avoid effects of immobilization
Gradual increase applied forces/loads
Recognize fixation strength & healing rates
Shoulder Stabilization Rehab
Mobility
Stability
Post-op principles
1. Type of repair
Arthroscopic vs. open
2. Location of tear/instability
Anterior
posterior
3. Tissue quality
Generalized capsular laxity throughout

Chronic vs. acute
4. Age of patient
5. Length of time from surgery
6. Ultimate functional goals
Open Bankart Repair

ROM Guidelines
Week 1:
0-90 flexion
Week 2:
0-100 flexion
ER/IR at 45 abd scapular plane: 0-25
Week 3-4
Flexion to 120-140
ER at 45 abd. scapular plane: 35-45
IR at 45 abd. in scapular plane to 45-60
Week 5-6: Flexion to 160 (tolerance)

ER/IR at 90 abduction:
IR to 75
ER to 70-75
Beyond 6-8 weeks progress as tolerated

ROM Principles
Rate of ROM progression based on:
Amount of motion present
End feel assessment
Capsular
Hard
Open
Degree of congenital laxity present
Which shoulder dominant?
Functional goals
Overhead athlete
Function below shoulder height
Contact sports
Guidelines
Arthroscopic/Open repair
Sling for 2-3 weeks

Sleep in immobilizer
for 4 weeks
Elbow/hand ROM
Hand gripping
exercises
Arthroscopic Bankart Repair

ROM Guidelines
Passive and gentle active assistive ROM exercise
Week 1:
Flexion to 70
Week 2:
Flexion to 90
ER/IR with arm 30 abduction
ER to 5-10
IR to 45
Week 3-4:
Flexion to 100
ER in scapular plane to 15-20
IR in scapular plane to 55-60
PROM
Progress ROM
Weeks 5-6:
Flexion to 145
ER at 45 abduction: 45-50
IR at 45 abduction: 55-60
Weeks 7-9:
Flexion to 160
Initiate ER/IR at 90 abduction
ER at 90 abduction: 70-80 at week 7
ER to 90 at weeks 8-9
IR at 90 abduction: 70-75
Avoid excessive ER, extension and horizontal abduction
Strengthening Guidelines
Arthroscopic Bankart
Week 0-2
Submaximal/painfree isometrics for
shoulder musculature
Rhythmic stabilization drills ER/IR
Proprioception drills
No IR strengthening for 2-3 weeks
(open repair only)
Week 3-4
Continue as above
Initiate light isotonics for shoulder
musculature
Tubing for ER/IR
Abduction, full can, sidelying ER, prone
rowing, biceps
Initiate scapula strengthening
Strengthening Guidelines
Bankart repair
Week 5-6
Progress exercise tubing ER/IR
(arm at side)
Scapular strengthening
PNF manual resistance
Week 7-9
Continue to progress isotonic
strengthening program
Throwers Ten
Continue PNF strengthening

Strengthening
Week 10-16
Continue strengthening exercises
Progress Throwers Ten program (for
overhead athlete)
Isotonic strengthening for entire shoulder
complex
PNF manual technique
Neuromuscular control drills
Bankart Repair
Week 10-14
Continue all flexibility exercises
Continue all strengthening exercises
Two hand plyometrics
Chest pass
Overhead
Side to side
One hand plyos Week 12-13

90/90
Dribble
May initiate light isotonic machine weight

training (week 12-14)
Functional Guidelines
Initiate interval sport
program ~ week 16
Return to contact sports
4-6 months
Return to overhead
athletics 6-9 months
Gradual return to mound
throwing
Karlsson, et al AJSM 01
Comparison open vs. arthroscopic Bankart repairs
GC arthroscopic repair (Suretac) v. 53 open
(anchors)
Follow-up average 28 months
Recurrence rate: arthroscopic 15%, open 10%
Rowe score: arthroscopic 93 points, open 89
points
Only significant difference ER @ 900 abd:
Arthroscopic: 900 (50-1350)
Open: 800 (25-1150)
Open Bankart Procedures

Results vary somewhat
92-97% good excellent results
Loss of motion is common
Especially external rotation
Some long term studies indicate recurrent

instability 17%
Magnusson: AJSM 03
Arthroscopic Bankart Procedures
Results vary somewhat

85-95% good excellent results
Loss of motion is uncommon
Recurrent instability is slightly higher than with an
open Bankart procedure
Rockwood & Matsen: The Shoulder 01
Long term results 95% G-E results, slight LOM
Kim: JBJS 03
Kim:Arthroscopy 03
Prospective randomized study Bankart repair

Arthroscopy Bankart in 62 pts (mean age 28)
Group I: immobilized for 3 weeks
Group II: immediate staged rehab
Follow-up average 31 months
Recurrence rate: no difference<3%
Final outcomes: no significant differences
Bottoni, Smith, et al: AJSM 06

Arthroscopic vs open Bankart Surgery
Follow-up 32 mos
Operative time:
Open: 149 mins.
Arthroscopic: 59 mins.
Failures: 2 open & 1 arthroscopic

LOM: greater loss in open group
Avg. loss compared to opposite shoulder
ER ROM: open 6.6 + 7.7 deg
ER ROM: arthroscopic 2.0 + 3 deg
Subjective scores equal between groups

Rehabilitation Following Posterior

Bankart Repair
Slower progression of ROM & function
Brace (immobilizer) for 6 weeks
Limit IR, horizontal adduction
Delay push-ups, bench press, pushing motions

for 12-14 weeks
Monitor posterior laxity

Emphasize ER strengthening
and scapular strengthening
Return to sports 9-12 months
Ultrasling ER
DonJoy ER 15/30
ROM exercises usually
begins at 4-6 weeks
postoperative
Much More
conservative than
anterior
Summary
Successful outcomes dependent on:
Type of surgery
Tissue quality
Size of tear
Gradually restore ROM
Re-establish dynamic stability &
neuromuscular control
Communication with MD!!!
Rotator Cuff and Labral Pathology: Post-Op
Bibliography
MedBridge Education
Rotator Cuff and Labral Pathology:
Presentation and Post-Operative Rehabilitation
Lenny Macrina, MSPT, SCS, CSCS
1.
Fleisig GS, Bolt B, Fortenbaugh D, Wilk KE, Andrews JR. Biomechanical comparison of
baseball pitching and long-toss: implications for training and rehabilitation. J Orthop Sports Phys
Ther. 2011;41(5):296-303.
2.
Lintner D, Mayol M, Uzodinma O, Jones R, Labossiere D. Glenohumeral internal rotation

deficits in professional pitchers enrolled in an internal rotation stretching program. Am J Sports
Med. 2007;35(4):617-621.
3.
Mazoue CG, Andrews JR. Repair of full-thickness rotator cuff tears in professional baseball
players. Am J Sports Med. 2006;34(2):182-189.
4.
Reinold MM, Macrina LC, Wilk KE, Dugas JR, Cain EL, Andrews JR. The effect of
neuromuscular electrical stimulation of the infraspinatus on shoulder external rotation force
production after rotator cuff repair surgery. Am J Sports Med. 2008;36(12):2317-2321.
5.
Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus and
deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007;42(4):464-469.
6.
Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of
motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523-527.
7.
Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and
total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med.
2011;39(2):329-335.
8.
Wilk KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic
glenohumeral instability. N Am J Sports Phys Ther. 2006;1:16-31.
9.
Wilk KE, Reinold MM, Macrina LC, et al. Glenohumeral Internal Rotation Measurements Differ
Depending on Stabilization Techniques. Sports Health Journal. 2009;1(2):131-136.

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Rotator Cuff and Labral

Leonard C. Macrina MSPT, SCS, CSCS

Leonard Macrina, MSPT, SCS, CSCS

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Good understanding of the tissues involved

Favorable outcomes expected

Leonard Macrina, MSPT, SCS, CSCS

Arthroscopic Repair of:

Rotator Cuff Repair

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Glenoid Labral Lesions

Common injury difficult to diagnose

Leonard Macrina, MSPT, SCS, CSCS

Leonard Macrina, MSPT, SCS, CSCS

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

THE GLENOID LABRUM

Originates from suprascapular,

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

GLENOID LABRUM FUNCTION

Acts as chock block

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Buford complex: 1.5-5%

Leonard Macrina, MSPT, SCS, CSCS

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Mechanisms of SLAP Lesions

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Glenoid Labral Lesions

Fall onto outstretched arms

Pushing heavy objects

Blow to the shoulder

Leonard Macrina, MSPT, SCS, CSCS

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Glenoid Labral Tears

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Glenoid Labral Tears

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Glenoid Labral Tears

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Glenoid Labral Tears

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Glenoid Labral Tears

Type II peel back

Leonard Macrina, MSPT, SCS, CSCS

American Sports Medicine Institute

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS

Glenoid Labral Lesions

During follow-through phase

Rotator Cuff and Labral Pathology: Presentation and Post-Operative Rehabilitation

Leonard Macrina, MSPT, SCS, CSCS