Xf;Aab ilJtatifJJi FOR~THE POSTSURGICAL ORTHOPEDICPATIENT FOR,- THE POSTSURGICAL ORTHOPEDICPATIENT Editedby LisaMaxey,PT Staff PhysicalTherapist, Sports Therapy, Calabasas, California JimMagnusson,PT Manager/Partner, PacificTherapy Services,Inc., Oxnard,California; Co-Owner, Performance Therapy Center Inc., Oxnard,Camarillo,and Thousand Oaks,California; TeamPhysicalTherapist, Oxnard College, TeamPhysicalTherapist, PacificSunsMinorLeagueBaseball Team, Oxnard,California with40 contributors with225illustrations 1\losby AHarcourt Health Sciences Company St.LouisLondonPhiladelphiaSydneyToronto ~ T A Mosby AHarcourt Health Sciences Company Editor:KellieWhite DevelopmentalEditor:ChristieM.Hart Project Manager:LindaMcKinley Senior ProductionEditor:JenniferFurey Designer:JuliaRamirez CoverArt: AngieRovtar Copyright 2001by Mosby,Inc. 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AHarcourtHealthSciencesCompany 11830WestlineIndustrialDrive St.Louis,Missouri63146 PrintedintheUnitedStatesofAmerica Library of Congress CataloginginPublicationData Rehabilitationforthepostsurgicalorthopedicpatient /[editedby]LisaMaxey,Jim Magnusson;with40 contributors. p.; em. Includesbibliographicalreferencesandindex. ISBN0-323-00166-1 I.Physicaltherapy.2.Orthopedic surgery-Patients-Rehabilitation. 3.Postoperative care.I.Maxey,Lisa.II.Magnusson.Jim. [DNLM:I.PhysicalTherapy-methods.2.PostoperativeCare-rehabilitation. 3.Orthopedic Procedures.WB460R34272001] RD736.P47R442001 6IS.8'2--dc2100-051100 0102 03 04 05 TG/MVY 9 8 7 6 5 4 3 2 Contributors Kelly Akin,PT SeniorHandTherapist, Department of PhysicalTherapy. CampbellClinic, Memphis,Tennessee MayraSaborio Amiran,PT PhysicalTherapist, HealthSouth. Camarillo.California JamesAndrews,MD ClinicalProfessor of Surgery, UABSchoolof Medicine,Divisionof Orthopaedic Surgery, Birmingham,Alabama; ClinicalProfessorof Orthopaedics& SportsMedicine, University of VirginiaMedicalSchool, Charlottesville,Virginia; ClinicalProfessor, Department of Orthopaedic Surgery, University of KentuckyMedicalCenter. Lexington,Kentucky; Senior Orthopaedic Consultant. WashingtonRedskinsProfessionalFootballTeam, Washington,DC; SeniorOrthopaedic Consultant, CincinnatiRedsProfessionalBaseballTeam, Cincinnati,Ohio; MedicalDirector, AmericanSportsMedicineInstitute, Orthopaedic Surgeon, AlabamaSportsMedicine&Orthopaedic Center, BirminghamAlabama CliveBrewster,MS,PT Market Coordinator-Outpatient, HealthSouth, LosAngeles,California Andrew A.Brooks.MD,FACS SouthernCaliforniaOrthopedic Institute, LosAngeles,California Nora Cacanindin,PT Director/Owner, Pro-ActiveTherapy. SanFrancisco,California JamesCalandruccio,MD AssistantProfessor, Orthopedic Department, University of Tennessee-CampbellClinic, Chief Hand/Upper Extremity Service. VAHospital. MemphiS.Tennessee Robert I.Cantu,MMSc,PT,MTC GroupDirector. Physiotherapy Associates, Atlanta,Georgia; Adjunct Instructor, Institute ofPhysicalTherapy. University of St.AugustineforHealthScience, St.Augustine,Florida Christina M. Clark,OTR,CHT HandClinic, SouthernCaliforniaOrthopedic Institute, VanNUys.California JamesCoyle,MD SpineSurgeon, Midwest SpineSurgeons. St.Louis,Missouri Deborah Mandis Cozen,RPT PhysicalTherapist. Pasadena,California RickB.Delamarter,MD Director, TheSpineInstitute, St.John'sMedicalCenter, SantaMonica,California Robert Donatelli, PhD,PT,OCS NationalDirectorof SportsRehabilitation, Physiotherapy Associates, Memphis,Tennessee v viContributors DanFarwell,PT,OPT AdjunctClinicalProfessor, Department ofBiokinesiologyandPhysicalTherapy, UniversityofSouthernCalifornia, LosAngeles,California; Owner/Director, BodyRxPhysicalTherapy, Glendale,California; Instructor, McConnellInstitute, MarinaDelRey,California RichardFerkel,MD ClinicalInstructorofOrthopedic Surgery, UCLA, LosAngeles,California; Attending SurgeonandDirector of SportsMedicine Fellowship, SouthernCaliforniaOrthopedicInstitute, VanNuys,California Mark Ghilarducci,MD Diplomate of theAmericanBoardofOrthopedic Surgery, Fellowof the AmericanAcademy ofOrthopedic Surgeons(AAOS), Camarillo,California Terry Gillette,PT,OCS,SCS Administrator, HealthSouthRehabilitationCenter ofWoodlandHills, WoodlandHills,California DavidGirard,PT,CHT PhysicalTherapist/CertifiedHandTherapist, HandsplusPhysicalTherapy, Northridge,California PatriciaA.Gray,MS,PT PhysicalTherapist, VisitingNurse&Hospice, CaliforniaPacificMedicalCenter, SanFrancisco,California KristenL.Griffith,OTR/L OccupationalTherapist, Department ofHandTherapy, CampbellClinic, Germantown.Tennessee JaneGruber,PT,MS,OCS OutpatientSupervisor, RehabilitationServices, NewtonWellesleyHospital, Newton,Massachusetts will Hall,PT,OCS ClinicDirector, Physiotherapy Associates, Cumming,Georgia Wendy J.Hurd,PT Director ofRehabilitation, SouthWest SportsMedicine, Phoenix,Arizona Frank Jobe,MD Associate, Kerlan-JobeOrthopaedic Clinic, ClinicalProfessor, Department ofOrthopaedics, UniversityofSouthernCaliforniaSchoolofMedicine, OrthopaedicConsultant, LosAngelesDodgers, LosAngeles,California; Orthopaedic Consultant, PGATour,SeniorPGATour, PalmBeachGardens,Florida RichardB.JohnstonIII,MD ClinicalInstructor, EmoryUniversity; Partner,HoughstonClinic,PC, Atlanta,Georgia Bert Mandelbaum,MD FellowshipDirector, SantaMonicaOrthopedic andSportsMedicineGroup, SantaMonica,California Benjamin M.Maser,MD AttendingPlasticSurgeon, plastic Surgery, PaloAltoMedicalFoundation, PaloAlto,California DavidPakozdi,PT,OCS Director, KineticOrthopaedicPhysicalTherapy, SantaMonica,California Mark Phillips,MD ClinicalAssistantProfessor, Department ofSurgery-Orthopedic Surgery, UniversityofIllinoisCollegeofMedicineatPeoria, Peoria,Illinois 1 LugaPodesta,MD Physiatrist, VenturaOrthopedicHandand SportsMedicalGroup, Oxnardand ThousandOaks,California; PhysiatristlConsu Itant, Kerlan-JobeOrthopedicClinic, LosAngeles,California; Physician, MajorLeagueBaseballUmpires, NewYork,NewYork; TeamPhysician, OxnardCollege, TeamPhysician, PacificSunsMinorLeagueBaseballTeam, Oxnard,California EdwardPratt,MD FacilityDirector, SpineMemphis, TheOrthopaedicClinic, MemphiS,Tennessee Diane Schwab,BA,DipPT,MS,MPA Owner, ChampionRehabilitation, SanDiego,California JessieScott,PT PhysicalTherapist, HealthSouth, SanFrancisco,California PaulSlosar,MD AttendingSurgeon, SpineCareMedicalGroup; AssistantDirector ofSurgicalResearch, TheSanFranciscoSpineInstitute, DalyCity,California Contributorsvii Steve Tippett,MS,PT,SCS,ATC AssistantProfessor, Department ofPhysicalTherapy, BradleyUniversity, Peoria,Illinois tGeoffrey Vaupel,MD PrivatePractice, CaliforniaPacificMedicalCenter,DaviesCampus, Department ofOrthopaedic Surgery, SanFrancisco,California KevinE.Wilk,PT NationalDirector,ResearchandClinicalEducation, HealthSouthRehabilitation, Birmingham,Alabama JulieWong,PT Co-Director, Pro-ActiveTherapy, SanFrancisco,California James Zachazewski,MS,PT,ATC,SCS Director ofRehabilitationServices, NewtonWellesleyHospital, Newton,Massachussets CraigZeman, MD BoardCertifiedOrthopedic Surgeon, VenturaOrthopedic SportsMedicalGroup, Oxnard,California t Deceased. I I. I Thisbookisdedicatedinmemory of Dr.GeoffreyVaupel. Dr.Vaupelwasa friend.educator,and advocateof physical therapy. Hispatientsbenefited fromhisknowledgethatphysical therapyinterventionwas anintegralfacetof a successful outcome.Wewillmisshimdearly. Nora CacanindinandJulieWong I Tomy parentsforproviding a loving home and forbeing a wonderful exampleof goodness.I have noexcuses. Tomyfriendsfortheirencouragementandtheirhelp.Tomy children forbringing moreloveintoour lives.And tomy husband forhis support,help,and commitment toour family. I LisaMaxey Tomy twochildren,Nicholasand Michelle. jim Magnusson I Preface T hepractice of physicaltherapy has gone through manytransformationsoverthepast50years.[t hasevolvedintoasciencethatiscontinuallybeing scrutinizedbythird-partypayerschallengingusto prove that what we do is effective and efficient. We are at acrucialpointinour professioninwhichweneed tojustifyhow many treatments are necessary totreat aconditionor[CD-9code;attimesthispracticeignores the individualwhom we are treating.Thisbook isnota"cookbook"forsuccess but rather acompass fromwhichthecliniciancanfindgUidance.Thistext is our effort to provide aresource that the clinician can reference as a gUideline inthe rehabilitation of the postsurgicalpatient. Wefeelthis is aunique text inthat we have brought together more than 30 authors fromaround the country.Many of the authors are wellpublished andsome are just plain good clinicians who are willing toshare theirexperientialphilosophy.Wewantedtheclinicians tobe able to visualize the common surgical approachestoeachcase(throughthephysicians'portion)andthenfollowthetherapist(s)guidelinesto establish an efficient treatment plan. The prototype of thistexthas notbeen explored,toourknowledge,in thismuchdepth(andwiththismanycontributors), especiallyAppendixA,TransitioningtheThrowing AthleteBacktotheField. Weexpect that withprogression and enhancement of surgical techniques, rehabilitation willevolve as well. Our hope isthat thistext willenhance our profession throughtheexchange ofinformationandthatsubsequenteditionscanrespondtothechangingneedsof the postoperative patient. Thisbook givesthephysicaltherapistaclearunderstanding ofthesurgicalproceduresrequiredforvariousinjuriessothatarehabilitationprogramcanbe fashioned appropriately.Each chapter presents the indicationsandconsiderationsforsurgery;adetailed look at the surgical procedure, including the surgeon's perspective regarding rehabilitation concerns; and therapy gUidelinestouseindesigningtherehabilitation program.Areasthatmightprovetroublesomeare noted,withappropriate ways toaddress problems. The indications and considerations forsurgery and the surgery itself are described by an outstanding surgeonspecializing ineacharea.Allof theinformation presented should be valuable inunderstanding the mechanics of the injury and therepair process. The therapy gUidelines sectionisdividedinto three parts: Evaluation Phases ofrehabilitation Suggestedhomemaintenance Every rehabilitation program begins with athorough evaluation at the initialphysical therapy visit. This providespertinentinformationforformulatingthetreatmentprogram. Asthepatient progresses throughthe program, assessment continues. Activities that are too stressfulforhealingtissues at onepointaredelayed. then reassessed when the tissue isready for the stress. Treatment measures are outlined intabular format for easyreference. Thephases eachpatient facesinrehabilitationare clearlyindicatedbothas awaytobreak theprogram intomanageable segments and to proVidereassurance to the patient that rehabilitation willproceed inan orderlyfashion.Thetimespancoveredbyeachphase and the goals of therehabilitationprocess during that phase arenoted. The exercises are carefully explained andphotographs are prOVidedforassistance. Homemaintenanceforthepostsurgicalpatientis an essential component of the rehabilitation program. Evenwhenthetherapistisabletofollowthepatient routinelyinthe clinic.thepatient isstillonhisor her own formost of the day.The patient must understand the importance of compliance with the homeprogram tomaximizepostoperativeresults.Inthesuccessful home maintenance program, the patient is the primary forceinrehabilitation,withthe therapist acting as an informedandeffectivecommunicator,anefficient coordinator,andamotivator.Whenthetherapistsuccessfullyfulfillstheseobligationsandthepatientis motivated and compliant. thehome maintenance program can be especially rewarding. When the patient isnot motivated or not compliant or possesses less than adequate pain tolerance,anononsense and forthright dialogue with the surgeon,referringphysician,rehabilitationnurse,oranyother professionalsinvolvedisessential.Timely,accurate, XI xiiPreface andstraightforward documentationalso issignificant inthe case of the"problem" patient.Emphasizing active patient involvement inan exercise program at home is even more imperative inlight of the prescriptive natureofcurrent managed care dictums. The keys to an effectivehome maintenance program arestructure,individuality,prioritization,andconciseness. The term structure refers toexercises that are welldefinedinterms of sets, repetitions, frequency,resistance, and technique.The patient must know what todoandhowtodoit.Homeprogramswithphotographs or video demonstrations are helpful inassisting thepatienttoseewhatisintended.Somecomputergenerated home exercise programs also offer adequate visualdescriptions ofthedesiredexercises.Stickfigures and drawings that the physical therapist makes are oftenunclear and confusing tothe patient. IndiViduality,intheclearestsense,involvesprescribing exercises that address the specificneeds ofa patient at aspecific point intime.Itincludes being flexible enough to allow the patient to work the home programintothedailyschedule as opposedtofollowing only an "ideal" treatment schedule. Other components inherent intheconcept ofindividuality includeassistance available to thepatient at home, financialimplications, geographicalconcerns thatinfluencefollowup,and the patient'S cognitive abilities. Prioritizationand concisenessinvolvemaximizing the useofthepatient'stimetoperformtheexercisesat home.Ifthepatientisbeingseenintheclinic,home exercises should stress activities not routinely performed intheclinic.Ifthepatientisconstrainedfortime,the therapist can identify the most beneficial exercises and prescribe them. It is best not to prescribe too many exercises tobe done at home.Ideally,the patient should havetoconcentrateonnomorethanfiveorsixata time.Tohelpkeepthenumber ofexercisesmanageable,the therapist should discontinue less taXing exercises as new exercises areaddedtotheprogram. LisaMaxey jimMagnusson SteveTippett Acknowledgments [ wouldliketogivemysincereappreciationtoallthe contributorsfortheircommitmenttotheirworkand forsharingtheirtimeandknowledgewithusforthe benefit of patients. I also want to thank HealthSouth for providingsomeoftheexercisephotographs.Special thanks to Clive Brewster forhis insights into book writing.Finally,thanks tomy colleagues-I've been fortunate tohaveworkedwith goodpeople. "Asmile must always be on our lips for any child to whomweofferhelp,foranytowhomwegivecompanionship or medicine. It would be very wrong to offeronlyourcures;wemustoffertoallourhearts." -Mother Teresaof Calcutta I Lisa Maxey Inthecourseofalifetimewemeetpeoplewhohave madeimpressionsonus;goodorbaditchangesus andshapesour visionofwhowewanttobecome.I would be remiss by not including the obvious individI uals(mother,father,andmytwobrothers).However, whenI firstembarked onacareer inthemedicalfield it was my grandfather,Dr.James Logie,who helped me understandthededicationofthose whoaspire tobecome the best intheir profession. I studied some of his ownhanddrawingsofthehumananatomywhenhe was inschool andhave seenhow throughhis dedicationtoservinghispatientshislifehasbeenblessed. Hehastaughtmetheimportanceofpatienceand showed me the art of flyfishing. Inmyexperience(J9years)workinginthefieldof physicaltherapyI alsohaveworkedwithindividuals who not only through clinical work but also through life experiencehavetaughtmethevalueofcompassion, dedication,empathy,andrespect.Althoughanumber of physical therapists have individually helped, the ones I've singled out also have positively influenced countless other therapists:DeeLillyMasuda,GarySouza,and RickKatz. Theundertakingofaprojectsuchasthisbook (whichrequirescountlesshours)shouldbedoneby someone who has the utmost consent of their spouse. Ifan author isnot married, I would highly suggest that he or she consider giving up any sociallifeuntildeadlineday.I thank God(andDee)forhelping meto find thatspecialpersoninmywife,partnerinlife,and peer-Tracy Magnusson,PT. JimMagnusson xiii Contents PARTONEUpper Extremity,1 1SoftTissueHealing Considerations After Surgery, RobertJ.Cantu 2 2Acromioplasty,11 Mark Phillips,SteveTippett I I, 3 4 5 6 Anterior Capsular Reconstruction,29 Frankjobe,DianeSchwab,CliveBrewster RotatorCuffRepairandRehabilitation,46 Mark Ghilarducci,LisaMaxey Extensor BrevisReleaseandLateralEpicondylectomy,71 jamesCalandruccio,Kelly Akin,KristenL.Griffith Reconstructionof theUlnar CollateralLigamentwithUlnar Nerve Transposition,82 jamesAndrews,Wendyj.Hurd,KevinE.Wilk 7CarpalTunnelSyndrome:PostoperativeManagement, BenjaminM. Maser,Christina M.Clark,David Girard 101 PARTTWOSpine,121 8LumbarMicrodiscectomy andRehabilitation, RickB.Delamarter,jamesCoyle,David Pakozdi 122 9LumbarSpineFusion, PaulSlosar,jessieScott 151 PARTTHREELowerExtremity,171 10TotalHipReplacement,172 EdwardPratt,PatriciaA.Gray 11OpenReductionandInternalFixationof theHip, EdwardPratt,MayraSaborioAmiran,PatriciaA.Gray 188 12Anterior Crudate Ligament Reconstruction, LugaPodesta,jim Magnusson,TerryGillette 206 13Arthroscopic LateralRetinaculumRelease, Andrew A.Brooks,DanFarwell 227 xv xviContents 14Meniscectomy andMeniscalRepair,243 Andrew A.Brooks,TerryGillette 15PatellaOpenReductionandInternalFixation,257 CraigZeman,DanFarwell 16TotalKneeReplacement,268 GeoffreyVaupel,NoraCacanindin,JulieWong 17LateralLigament Repair,288 RichardFerkel,RobertDonatelli,WillHall 18OpenReductionandInternalFixationof theAnkle,302 RichardFerkel,RobertDonatelli,will Hall 19Ankle Arthroscopy,314 RichardFerkel,DeborahMandisCozen 20AchillesTendonRepair andRehabilitation,323 BertMandelbaum,JaneGruber,JamesZachazewski Appendix ATransitioning theThrowing AthleteBacktotheField,350 LugaPodesta X ~ A a bititativJi FOR~THE POSTSURGICAL ORTHOPEDICPATIENT , t C/..ay fer1 SoftTissueHealingConsiderations AfterSurgery Robert 1.Cantu Physicaltherapistsworkdailyonconnectivetissuesthataredynamicandhavethecapacityfor change. Changes inthese tissues are driven by anumber offactors,including trauma,surgery,immobilization, posture, and repeated stresses. The physical therapist must have a good working knowledge of thenormal histologyandbiomechanicsofconnectivetissueand understandthewayconnectivetissuerespondsto immobilization,trauma,and remobilization.Bothexperiencedandnovicephysicaltherapistscanbenefit fromagood"mentalpicture"of connectivetissues in operation. Becausethistextprimarily considerspostsurgicalrehabilitation,anoperationaldefinitionofsurgeryisin order. For the purpose of considering injury and repair ofsofttissues,surgerymaybedefinedascontrolled traumaproducedbya trainedprofessionaltocorrectuncontrolledtrauma.Thereasonforthisunusualdefinitionisthat connective tissuesrespond incharacteristic ways toimmobilization and trauma. Because surgery isitselfaformoftraumathatisusuallyfollowedby someformofimmobilization,thephysicaltherapist must understand the way tissuesrespondtobothimmobilizationand trauma. Thischapterbeginsby dealingwiththebasichistologyandbiomechanics of connectivetissue.It then presentsthehistopathologyandpathomechanicsof connective tissues (Le.,the way connective tissues respond to immobilization, trauma, andremobilization). Finally itthen addresses some basic principles of soft tissuemobilizationbased on the connective tissue response to immobilization, trauma, and remobilization. Histology andBiomechanics of Connective Tissue Theconnectivetissuesysteminthehumanbodyis quiteextensive.Connectivetissuemakesup16%of thebody'sweightandholds25%ofthebody'swater.9 The "soft" connective tissues formligaments, tendons,periosteum,jointcapsules,aponeuroses,nerve and muscle sheaths, blood vessel walls, and the bed and framework of the internal organs. If the bony structures wereremoved,asemblance ofstructure wouldremain fromthe connective tissues. Amajorityofthetissuesaffectedbymobilization are connective tissues.During joint mobilization, forexample,thetissuesbeingmobilizedarethejoint capsule and the surrounding ligaments and connective tissues. The facetjoint space ismerely a"space built for motion."Arthrokinematic rules are followed,but the tissue beingmobilizedisclassifiedas connective tissue. Thereforeabackgroundknowledgeofthehistology and histopathology of connective tissues is essential for thepracticing physicaltherapist. NormalHistologyandBiomechanics ofConnective TissueCells Connective tissue has two components: the cells and the extracellular matrix.The cellof primary importance is thefibroblast.Thefibroblastsynthesizesalltheinert componentsofconnectivetissue,includingcollagen, elastin,reticulin,and groundsubstance. TheExtracellularMatrix The extracellular matrixofconnective tissueincludes connectivetissuefibersandgroundsubstance.The connective tissue fibersinclude collagen (the most tensile),elastin,andreticulin(themost extensible).Collagen, elastin, and reticulin prOVidethe tensile support that connectivetissueoffers.Extensibilityor thelack ofitis drivenby the relative density and percentage of the connective tissue fibers.Tissues withless collagen densityandagreaterproportionofelastinfibersare morepliablethantissueswithagreaterdensityand proportion of collagenfibers. Thegroundsubstanceofconnectivetissueplaysa verydifferentroleinthe connective tissueresponse to immobility,trauma,andremobilization.Theground substanceistheviscous,gel-likesubstanceinwhich the cells and connective tissue fiberslie.Itacts as alu2 SoftTissueHealing ConsiderationsAfter SurgeryCHAPTER13 [ Looseirregular , periosteum, s, dermis areas ofhigh mechanical stress Superficial fascialsheaths, muscle and nerve sheaths,support sheaths of internal organs FromCantuR,Grodin A:Myofascial manipulation: theory and clinical application,Gaithersburg, MD,1992, Aspen. ! bricant for collagenfibersin conditions of normal mobility andmaintains acrucialdistancebetweencollagenfibers.The ground substance alsoisa medium for the diffusion of nutrients andwasteproducts andacts asamechanicalbarrier forinvadingmicroorganisms. Ithasamuchshorterhalf-lifethancollagenand,as will be discussed, is much more quickly affected by immobilizationthancolIagen. 12 Three TypesofConnective Tissue Connectivetissueisclassifiedaccording tofiberdensity and orientation. The three types of connective tissuefound in thehuman body are dense regular,dense irregular,andlooseirregular 6,13(Table1- I). Denseregularconnectivetissueincludesligaments andtendons(Fig.1-]). Thefiber orientationisunidirectional for the purpose of attenuating unidirectional forces. The high density of collagen fibers accounts for thehighdegreeof tensilestrengthandlackof extensibility in thesetissues.Relativelylow vascularity and water content account for theslow diffusion of nutrientsandresultingslowerhealingtimes.Denseregular connectivetissueisthemost tensileandleastextensibleof theconnective tissue types. Dense irregular connective tissue includes joint capsules,periosteum, and aponeuroses.The primary difference between dense regular and dense irregular connectivetissueisthat denseirregular connective tissue has a multidimensional fiber orientation (Fig.]-2). lhis multidimensionalorientationallowsthetissuetoattenuate forcesin numerous directions.The density of collagen fibersis high, producing a high degree of tensilestrengthandalow degreeof extensibility.Dense irregular connective tissue also has low vascularity and water content,resulting inslow diffusion of nutrients and slowerhealing times. Fig.1-1.Denseregularconnectivetissue.Notetheparallelcompactarrangement of the collagen fibers.(Modified from Williams P,Warwick R, editors:Gray'sanatomy.ed35,Philadelphia,1973,WBSaunders.) Fig. 1-2.Denseirregular connective tissue with multidimensional compact arrangementof collagenfibers.(ModifiedfromWilliamsP,WarwickR, editors:Gray'sanatomy,ed35.Philadelphia.1973,WB Saunders.) 4PartIUptr [,xfrc11(ity Looseirregular connective tissueincludes,butisnot limited to,the superficialfascialsheath of the body directlyundertheskin,themuscleandnervesheaths, and the bed and framework of the internal organs. Similarlytodense irregular connectivetissue,looseirregPreloadTensile forcePostload ~ ~ Jularconnectivetissuehasamultidimensionaltissue orientation.However,thedensityofcollagenfibersis muchlessthanthat of denseirregular connectivetissue. The relative vascularity and water content of loose irregular connective tissue ismuch greater than dense regularanddenseirregularconnectivetissue.Thereforeitismuch more pliable and extensible and exhibits faster healing times after trauma.Looseirregular connective tissue also isthe easiest tomobilize. NormalBiomechanicsofConnective Tissue Connectivetissueshaveuniquedeformationcharacteristicsthatenablethemtobeeffectiveshockattenuators.Thisistermedtheviscoelasticnatureof connective tissue. ISThis viscoelasticity isthe very characteristic that makes connective tissue able to change based on the stresses applied toit.The ability of connectivetissuetothickenorbecomemoreextensible basedonoutsidestressesisthebasicpremisetobe understood by the manual therapist seeking toincrease mobility. Intheviscoelasticmodeltwocomponentscombine togiveconnectivetissuesitsdynamic deformationattributes.The firstistheelasticcomponent,whichrepresents atemporary change inthe length of connective tissue subjected to stress (Fig.I-3). This isillustrated by aspring,whichelongates whenloadedandreturnsto itsoriginalpositionwhenunloaded.Thiselastic component isthe "slack" inconnective tissue. The viscous,or plastic, component of the model represents the permanent change in connective tissue subjectedtooutsideforces.Thisisillustratedbyahydraulic cylinder and piston(Fig.1-4).When aforceis placedonthepiston,thepistonslowlymovesoutof thecylinder.Whentheforceisremoved,thepiston doesnotrecoilbutremainsatthenewlength,indicating permanent change.Thesepermanent changes resultfromthebreakingofintermolecularandintramolecular bonds between collagen molecules, fibers, andcross-links. Theviscoelasticmodelcombinestheelasticand plasticcomponentsjust described(Fig.1-5).When subjected to amild forceinthe midrange of the tissue, the tissue elongates inthe elastic component, then returns to its original length.If,however,the stress pushes thetissuetotheendrange,theelasticcomponentis depletedandplasticdeformationoccurs.Whenthe stressisreleased,somepermanentdeformationhas occurred.Notethatnotalltheelongationispermanentlyretained,only aportion. Fig. 1-3.The elastic component of connective tissue.(From Grodin A,Cantu R:Myo[ascialmanipulation:theoryand clinicalmanagement.Centerpoint, NY,1989,ForumMedicalPublishers.) PreloadTensile forcePostload , , Fig,1-4.Theviscous,orplastic,componentof connectivetissue.(From GrodinA,CantuR:Myofascialmanipulation:theoryandclinicalmanagement,Centerpoint, NY,1989,ForumMedical Publishers.) PreloadTensile forcePostload Fig. 1-5.The viscoelastic nature of connective tissue.(From Grodin A,Cantu R:Myofascialmanipulation:theoryandclinicalmanagement,Centerpoint, NY,1989,ForumMedical Publishers.) Clinically,thisphenomenonoccursfrequently.For example, aclient with afrozenshoulder that has only 90degreesofelevationismobilizedtoreacharange ofmotionof1IOdegreesbytheendofthetreatment session.Whentheclientreturnsinafewdays,the rangeofmotionofthat shoulderislessthan110degrees but more than 90 degrees. Some degree of elongationislost,and someisretained. This viscoelastic phenomenon can befurtherillustrated by theuse of stress/strain curves.Bydefinition, stressistheforceappliedperunitarea,andstrainis thepercent change inlength.When connective tissue isinitiallystressedorloaded,verylittleforceisrequired toelongate the tissue.However,as more stress isappliedandtheslackorspringistakenup,more forceisrequiredandlesschange occursinthe tissue (Fig.I-6).Whenthetissueissubjectedtorepeated Soft Tissue Healing Considerations After SurgeryCHAPTER15 ,Stress reapplied Time Fig.1-6.Stress/straincurvesindicating theprogressiveelongationof connective tissue with repeated stresses.(From Grodin A,Cantu R:Myofascial manipulation:theoryandclinicalmanagement,Centerpoint,NY,1989, ForumMedicalPublishers.) stresses, the curve shows that after each stress the tissue elongates,thenonlypartiallyreturnstoitsoriginallength. Some lengthis gained each time the tissue istakenintotheplasticrange.Thisphenomenonis seenclinicallyinrepeatedsessions of therapy.Range of motionis gained during asession, withsome of the gainbeing lost between sessions. Immobilization Immobilization and trauma significantly change the histologyandnormalmechanicsofconnectivetissue.A majority of the hallmark studies inthe area of immobilizationfollowthe same basic experimentalmode.i-S,ls Laboratory animals are fixatedinternally for varying periods. The fixationis removed and the animals are then sacrificed.Histochemicalandbiomechanicalanalyses areperformedtodeterminechangesinthetissues.In somestudiesthefixationisremovedandtheanimals are allowed tomove the fixatedjoint for aperiodbefore the analysis is performed. This is done to determine the reversibility of the effects of immobilization. 10 Macroscopically,fibrofattyinfiltrateisevident inthe recesses of the immobilized tissues. With prolonged immobilizationtheinfiltratesdevelopamorefibroticappearance, creating adhesions inthe recesses.These fibrotic changes occur in the absence of trauma. Histologic andhistochemicalanalysesshow significantchanges primarilyinthe groundsubstance,withnosignificant lossofcollagen.The changes inthe ground substance Fig. 1-7.Thebasket-weave configuration of connective tissue. Withimmobilizationthe distancebetweenfibersisdiminished,forming cross-link adhesions.(FromCantuR.Grodin A:Myofascial manipulation:theory and clinical application,Gaithersburg.MD,1992. AspenPublishers.) consist of substantial losses of glycosaminoglycans and water. Because aprimary functionof ground substance is binding water to assist inhydration, the loss of ground substance results inarelatedloss of water. Another purpose of ground substance is tolubricate adjacent collagenfibersandmaintainacrucialinterfiber distance. If collagen fibers approximate too closely, the fibers willadhere to one another. These cross-Jinks create aseries ofmicroscopic adhesions that limit the pliability andextensibility of the tissues(Fig.1-7). Furthermore,becausemovement affectsthe orientation of newly synthesized collagen, the collagen inthe immobilizedjointsstudiedwaslaiddowninamore haphazard,"haystack" arrangement. This orientation restrictstissuemobilityfurtherbyadheringtoexisting collagenfibers(Fig.1-8). Biomechanicalanalysisrevealsthatasmuchas 10timesmoretorqueisnecessary tomobilizefixated joints than normal joints. After repeated mobilizations, these joints gradually return tonormal. The authors of these studies implicate both fibrofattymicroadhesions andincreasedmicroscopiccross-linkingofcollagen fibers inthe decreased extensibility of connective tissues. Remobilization Availableresearchseems tosuggest that mobility and remobilizationpreventthehaystackdevelopmentof collagen fibers and stimulate the production of ground substance.Whenconnectivetissueisstressedwith movement,the tissuerehydrates,collagen cross-links arediminished,andnewcollagenislaiddownina moreorderlyfashion.Thecollagentendstobelaid _._._-6PartIUjjer[;drtJKify downinthedirectionoftheforcesappliedandinan appropriatelength. Additionally,macroadhesionsformedduringthe immobilization period partially elongate and partially rupture during theremobilization process,increasing the overallmobilityof thetissue.Bothpassivemobilizationandactiverangeofmotionproducesimilar results. Trauma Thesestudieshavelimitedapplicationbecausethey involvetheimmobilizationofnormal,healthyjoints. Fig.1-8.Therandomhaystackarrangement of immobilizedscartissue creating additional adhesions.(FromCantuR.Grodin A:Myofascialmanipulation:theory and clinical application,Gaithersburg, MD.1992. Aspen Publishers.) Tocomplete this discussion, we must superimpose the effectsoftrauma and scar tissue onimmobilization. Scar Scartissuemechanicsdiffersomewhatfromnormal connective tissue mechanics. Normal connective tissue ismature and stable,withlimitedpliability.Immature scartissueismuchmoredynamicandpliable.Scar tissueformationoccursinfourdistinctphases.Each ofthesephases shows characteristic differencesduringphases ofimmobilizationandmobilization/'s Thefirstphaseofscartissueformationistheinflammatoryphase. This phase occurs immediately after trauma. Bloodclotting begins almost instantly and isfollowedbymigrationofmacrophagesandhistiocytestostartdebridingthearea.Thisphaseusually lasts 24 to 48 hours, and immobilization isusually importantbecauseofthepotentialforfurtherdamage withmovement.Some exceptionstoroutineimmobilizationexist.Forexample,inan anterior cruciate ligament (ACL)reconstruction inwhich the graft is safely fixatedand damage fromgentle movement isunlikely, theremaybeagreatadvantageinmovingthetissue as early as the firstday after surgery. Thesecondphaseofscartissueformationisthe granulationphase.Thisphaseischaracterized by an uncharacteristic increase intherelative vascularity of the tissue.Increased vascularity isessential to ensure proper nutrition tomeet the metabolic needs of the repairingtissue.Thegranulationphasevariesgreatly depending onthe typeof tissueandtheextent of the damage. Generally speaking, the entire process of scar tissueformationislengthenedifthedamagedtissue ,oj,' 1J 0 _ '/9'1)'"",,?/ 'S;,s,.f

il'v. (90:

Stage 3 Time Fig.1-9.Relationship of tissuepliability torelative risk of injury. Stage 1Stage 2Stage 4 SoftTissueHealing ConsiderationsAfter SurgeryCHAPTER17 isless vascular initsnontraumatized state.For example,tendons andligamentsrequiremore time forscar tissue formation than muscle or epithelial tissue.Movement ishelpfulinthis phase,although the scar tissue canbeeasilydamaged.Thephysicianandtherapist needto work closely to determine the extent of movement relative tothe risk. Thethirdphase ofscar tissueformationisthefibroplasticstage.Inthisstagethenumberoffibroblasts increases, as does therate of production of collagenfibersandgroundsubstance.Collagenislaid downat anacceleratedrateandbindstoitselfwith weakhydrostaticbonds,makingtissueelongation mucheasier.Thisstagepresentsanexcellentwindow of opportunity forthe reshaping and molding of scar tissue without great risk of tissue re-injury. This stagelasts3to8weeks depending onthehistologic makeupandrelativevascularity of thedamagedtissue.Scartissueatthisphaseislesslikelytobeinjured but isstilleasily remodeled with stresses applied (Fig.1-9). The finalphase of scar tissue formationisthe maturation phase. Collagenmatures, solidifies,and shrinks duringthisphase.Maximalstresscanbeplacedon the tissue without risk of tissue failure.Because collagensynthesis isstillaccelerated,significantremodeling can take place when appropriate mobilizations are performed.Conversely,ifthey areleftunchecked,the collagen fiberscan cross-link and the tissue can shrink significantly.Attheendofthematurationphase.tissue remodeling becomes significantly more difficult because the tissue reverts to amore mature, inactive, and nonpliable status. SurgicalPerspective Surgeryhas beendefinedinthischapter as controlled traumaproducedbya trainedprofessionaltocorrectuncontrolled trauma.Postsurgical cases are subject to the effects of immobilization.trauma, and scar formation. However,theyhavetheadvantageofresultingfrom controlledtrauma.Thescar tissue formedbysurgery isusually more manageable than scar tissue formedby uncontrolledtrauma or overuse. When dealing with scar tissue after surgery, the physical therapist should remember the follOWing guidelines: Assess the approximate stage of development of the scartissue.Althoughthetimelinesvary,vascular tissuematures fasterthannonvascular tissue. Whenever possible, movement is helpfulincontrolling the direction and length of the scar tissue. Communicate with the referring physician regarding the amount of movement that is appropriate. Inastudy performedbyFlowers and Pheasant, IIcasted joints regainedmobilitymuchfasterthanfixatedjoints. ThisisprobablybecauseacastdoesnotproVide the same immobilization as rigid fixation.The small amounts of movement allowedincasted jointsmay beenoughtopreventsome ofthechanges caused byrigidfixation. Recognizethe window ofopportunity tostress scar tissue,andkeepinmindtheassociatedriskoftissueinjuryormicrotrauma(seeFig.I-9).Although the potential to change scar tissue may be greater in earlier stages, the risk of damage ishigher. The third stage appears tobe the stage at which the reward of mobility work exceeds the risk. The therapist should proceed with caution inthe second stage of scar tissueformation,recognizingthatsomeriskmaybe necessary ifoptimalresults are tobe obtained. In1945, JohnMennell12a said"there are only two possibleeffects of any movement or massage:they are reflex andmechanical."Thefollowingsummaryemphasizes the goals of the mechanicalchanges ofmobility work: Mobilityworkallowsforthehydrationandrehydrationof connective tissues. Mobility work causes the breaking andsubsequent prevention of cross-links incollagen fibers. Mobilityworkallowsforthebreaking andpreventionofmacroadhesions. Mobilityworkallowsfortheplasticdeformation and permanent elongationof connective tissues. Mobilitywork allowsforthelayingdownof collagen fibersand scar tissue inthe appropriate length anddirectionofthe stresses applied. Mobilityworkallowsforthemoldingandremolding of collagen fibersduring the fibroplastic and maturationstages ofscar tissue formation. Mobilitywork prevents scar tissueshrinkage. Mobilityworkallowsforthemoregeneralizedeffectsof increasedbloodflow,increased venous and lymphatic return, and increased cellular metabolism. Principles fo of Connectiv This section attempts to integrate the principles of basic scientificresearch and years of clinicalexperience into ~ s e r i e s of techniques useful for the physical therapist intreating immobilizedtissue. TheThree-Dimensionality of Connective Tissue Connective tissue is three-dimensional. Especially after trauma andimmobilization,thescar tissuecanfollow lines of development not consistent with the kinesiology or arthrokinematics of the area. Therefore the ability to feelthe location and direction of the restriction becomes important inthemobilizationof scar tissue. 8PartIUj}tr ,xtrtHUty Fig.1-10.Theprincipleofshortandlong.Softtissueimmobilizationisperformedina shortenedrange,thenimmediately elongated. Creep Creepisanothertermfortheplasticdeformationof connectivetissue.Activescartissueismore"creepy" thannormalconnectivetissue(i.e.,itismoreeasily elongatedbyexternalforces).Creepoccurswhenall the"slack"hasbeenlet out of thetissue.It isbest accomplishedwithlow-load,prolongedstretchingbut alsocanbeaccomplishedwithothermanualtechniques.Dynamicsplintingisanothertechniqueused toelongateconnectivetissue.Thetissueshouldbe elongatedalong thelines of normalmovement;however,at timestherestrictivelesionmay not followthe line of movement.Thetherapistmustidentifythedirection of the restriction andmobilize directly into the restriction.Thismaybeatransverseorhorizontal plane.Mobilizingthescarinthedirectionoftherestriction usually results inmore movement along conventionalplanes. ThePrincipleofShortandLong Theprinciple of short andlong istheideathat tissues mobilized in a shortened range often become more extensiblewhentheyareimmediatelyelongated(Fig. 1-10).Forexample,inalateralepicondylitis,crossfrictionmassagemaybeperformedoverthelateral epicondylewiththeelbowpassivelyflexedandthe wrist passively extended.Immediately after the cross-frictionintheshortenedrange,thetissueisstretched intotheplasticrange.Intheshortenedrange,deeper tissues canbeaccessed.Whentissueistaut, only the more superficial layers can beaccessed.When the tissuehas some slack,the deeper tissues canbe accessed andpreparedforstretching. The principle of short andlonghasneuromuscular implications aswell.If amuscleisguarded,shortening the muscle by mobilizing it has aninhibitory effect that makesimmediate elongationeasier. TechniquesforMobilization ofConnective Tissues The following techniques and associated photographs illustrate somesimplemanualtechniqueseffectivein mobilizing softtissues. MuscleSplay Muscle splayisa termthatimplies a widening or separationoflongitudinalfibersofmuscleorconnective tissuesthathaveadheredtooneanother(Fig.I-II). Theseadhesionslimittheabilityof thetissuetobe lengthened passively or shortened actively. When musclebundlesor connectivetissue bundlesstick together the muscle fibersbecome less efficient intheir contractions.For example,muscle splay inthe wrist flexors ofSoftTissueHealingConsiderationsAfterSurgeryCHAPTER19 Fig.1-11.Thesplaying,orlongitudinal separation, of fascialplanes.Fig.1-13.Transversemovement of fascialplanes. Fig.1-12.Thebending of thefascialsheathsurrounding themuscles. tenproducesaslightlygreatergripstrengthimmediately after soft tissue work. This isnot greater strength, but greater muscle efficiency produced by increased soft tissuepliability. Themuscle cancontract more efficiently withinits connectivetissuecompartments. TransverseMuscleBending Transversemusclebendingtakesthecontractileunit and mobilizes it perpendicular to the fibers(Fig.1-12). Thisperpendicularbendingmobilizesconnectivetissuesinawaysimilartothebending of a gardenhose (Fig.1-13).Theconnectivetissuesheathsurrounding Fig.1-14.Longitudinalstroke clearingfasciaaway froma bony surface. amusclemaybelikenedtothehoseitself,withthe musclebeinganalogoustothewaterinsideit.Ifthe connective tissue sheath isstiff and rigid.the muscle insidehasdifficulty contracting.Theunforgiving sheath does not allow themuscle to expandtransversely, creatingalackofefficiencyandalow-grade"compartment syndrome." Bymobilizing thesemuscle sheaths, overallmobilityisenhancedalongplanesofnormal movement. Bony Clearing Bonyclearingissimilartomusclesplay,exceptthe mobilizationisappliedlongitudinallyalongthesoft tissuesthatborderorattachtoabonysurface(Fig. 1-14).A goodexampleof thisislongitudinalstroking of the anterior lateralborder of thetibiainconditions suchasshinsplints.Theconnectivetissuesalong the borderofthetibiathickenandbecomeadhered,and thetherapistattemptstomobilizethetissuesinthis plane. 10Part IUjjtr E;drtilUty Cross-Friction Cross-frictionmassage, which was developed and advocatedbythelateJamesCyriax,isexcellentformobilizing scar tissue and nonvascular connective tissues. Itisanaggressiveformofsofttissuemobilizationdesigned tobreak scar tissue adhesions andtemporarily increase the blood flowtononvascular areas. Ligaments andtendonsstrugglingtohealcompletelyareexcellentcandidatesforcross-frictionmassage.Thistechnique can be used on scar tissue as welland should be performedinmany differentanglestoaccess fibersin alldirections. BasicprinciplesandgUidelinesforsofttissuemanagement aftersurgery havebeen outlined. The stages of scar tissue formationhave been discussed. The time framesforthese stages are variable based onthe vascularity of the tissues and the surgicalprocedure performed.They aredelineatedinmoredetailinthe following chapters. Thephysicaltherapistmustunderstandconnective tissue responses to immobilization, trauma, remobilization,andscar remodeling totreat injured tissues effectively.Awarenessoftheseprinciplesalongwithgood physician and client communication ensures consistently effectivemanagement ofpostsurgicalrehabilitation. REFERENCES I. Akeson WH, AmielD: The connective tissue response to immobility: a study of the chondroitin 4 and 6 sulfate and dermatansulfatechangesinperiarticularconnectivetissueof controlandimmobilizedkneesofdogs.ClinOrthop51: 190, 1967. 2.AkesonWH, Amiel0: Immobility effects of synovial joints: the pathomechanics of joint contracture. Biorheology17:95, 1980. 3.AkesonWHet al:Collagencross-linking alterations inthe joint contractures:changesinthereduciblecross-linksin periarticularconnectivetissueafter9weeksofimmobilization, ConnectTissueRes5: 15,1977. 4.AkesonWHetal:Theconnectivetissueresponsetoimmobility: an accelerated aging response,ExpGerontoI3:289,1968. 5.Akeson WHetal:Theconnectivetissueresponsetoimmobilization: biochemical changes inperiarticular connective tissue of therabbitknee,ClinOrthop93:356,1973. 6.Copenhaver WM,BungeRP,BungeMB:Bailey'stextbookof histology,Baltimore,MO,1971,Williams & Wilkins. 7.CummingsGA:Softtissuecontractures:clinicalmanagement continuing education seminar,course notes, Atlanta. GA,March 1989,GeorgiaStateUniversity. 8.Cummings GS,Crutchfield CA,Barnes MR:Orthopedic physicaltherapy series: soft tissue changesincontractures,Atlanta, 1983,StokesvillePublishing. 9.DickeE,Schliack H,Wolff A:Amanual of refleXivetherapy of the connectivetissue,Scarsdale,NY.1978, Sidney S.Simon. 10.EvansE etal:Experimentalimmobilizationandmobilization of ratkneejoints,j Bonejoint Surg42A:737.1960. II. FlowersKR,PheasantSO:Theuseof torqueanglecurves in the assessment of digital stiffness,j HandTherapy,p.69, Jan-March1988. 12.HamAW.CormackDH:Histology,Philadelphia,1979,JB Lippincott. 12a.Mennell }B:Physical treatment by movement,manipulation and massage,ed5,London,1945,Churchill. 13.SapegaAA et al:Biophysical factors in range-of-motion exercise,PhysicianSportsMed9:57,1981. 14.Warwick R,Williams PL:Gray's anatomy.ed35, Philadelphia, 1973,WB Saunders. IS.Woo Set al: Connective tissue response to immobility, ArthritisRheum18:257,1975. Acromioplasty MarkPhillips SteveTippett Before the broad topic of acromioplasty is addressed, thetopicofsubacromialimpingementsyndrome must be explored. In1972 Neer described subacromial impingementasadistinctclinicalentityinhislandmark article.41 Hecorrelatedtheanatomy of thesubacromial space with the bony andsoft tissue relationships anddescribed theimpingement zone.Neer also described a continuum of three clinical and pathologic stagesYThisstudy providesa basisforunderstanding the impingement syndrome, which ranges from reversible inflammation to full-thickness rotator cuff tearing.Therelationshipsamong the anterior third of the acromion,coracoacromialligament,andacromioclavicularjoint andtheunderlying subacromialsofttissues,includingtherotatorcuff,remainthebasisfor most of thesubsequentsurgery-relatedimpingement studies.Many otherresearchershavecontributedto currentknowledgeofthesubacromialshoulderimpingement syndrome. The works of Meyer,40 Codman, 16 Armstrong,4Diamond,17andMcLaughlinandAsherman39 provide a historicalperspective. AnatomicEtiologicFactors Anyabnormalitythat disruptstheintricaterelationshipwithinthesubacromialspacemayleadtoimpingement.Bothintrinsic (intratendinous) and extrinsic(extratendinous)factorshavebeenimplicatedas etiologiesoftheimpingementprocess.Nirschl44 eloquently describedthe roleof muscle weakness within therotator cuff,leading totensionoverload,humeral head elevation, and changes in the supraspinatus tendon, which is usedmost often in high-demand, repetitiveoverheadactivities.Otherauthors3,31 .60havedescribedinflammationandthickeningofthebursal contentsandtheirrelationshiptotheimpingement syndrome. lobe et aPO,31studied the role of microtrauma andoveruseinintrinsic tendonitisandglenohumeral instability and their implications for overhead-throwing athletes. Intrinsic degenerative tenopathy also has been discussedasanintrinsic causeofsubacromialimpingement symptoms.48 Extrinsic or extratendinous etiologic factors form the secondbroad category of causes of impingement syndrome. Raresecondary extrinsic factors (e.g.,neurologic pathology secondary to cervical radiculopathy, supraspinatus nerve entrapment) arenot discussed here,but theprimary extrinsic factorsandtheir anatomic relationships are of primary surgical concern. Theunique anatomy of the shoulder joint sandwiches the soft tissue structures of the subacromial space(Le.,rotator cuff tendons, coracoacromial ligament,long head of biceps, bursa)betweentheoverlyinganterioracromion, acromioclavicular joint, andcoracoid process andthe underlying greater tuberosity of the humeral head and the superior glenoid rim. Bigliani's description of three primaryacromialtypesandtheircorrelationtoimpingementandfull-thicknessrotatorcuff tearshas beensupported by Toivonen.9,58Acromioclavicular degenerative joint disease also canbe anextrinsic primary etiologyofimpingementdisease.41 ,42Manyauthors support Neer's original position on the contribution of acromioclavicular degenerative joint disease to the impingement process.33,63The os acromiale, the unfused distalacromialepiphysis,alsohas beendiscussedas aseparateentityandapotentialetiologicfactorrelatedtoimpingement.8 Glenohumeralinstabilityisa secondary extrinsic cause or contribution toimpingement. Its relationship to the impingement syndrome is poorlyunderstood,butithelpsexplainthefailureof acromioplastyinthesubsetof young,competitive, overhead-throwingathleteswithaclinicalimpingement syndrome. 21,23,31 DiagnosisandEvaluation of the Impingement SyndromeHistory and physical examinations are crucial in diagnosing subacromialimpingement syndrome.Findings may besubtle andsymptoms may overlapin thevarious differential diagnoses;thereforeappreciating the impingement syndrome symptom complex may be difficult. The classic history has an insidious onset anda chroniccomponentthatdevelopsovermonths,usually inapatientover40yearsold.Thepatientfrequently describes repetitive activity during recreation, 11 12PartIUj}tr Extrt1futy recreationalsports,competitiveathletics,andwork. Painisthemostcommonsymptom,especiallypain withspecifichigh-demandorrepetitiveaway-fromthe-chest and overhead shoulder activities. Night pain isseenlaterinimpingementsyndrome,aftertheinflammatoryresponsehasheightened.Weaknessand stiffness may occur secondary to pain inhibition. Iftrue weakness persists after the pain iseliminated, the differentialdiagnoses of rotator cuff tearing or neurologic cervicalentrapment-typepathologiesmustbeaddressed.Ifstiffnesspersists,frozenshoulder-related conditions(e.g.,adhesivecapsulitis,inflammatory arthritis, degenerative joint disease) must be ruled out. Youngerathleticandthrowingpatientsneedcontinualassessment forglenohumeralinstability. Thephysicalexaminationofapatientwithimpingement syndrome focuses on the shoulder and neck regions.Physicalexaminationoftheneckhelpsrule out cervicalradiculopathy,degenerative joint disease, and other disorders of the neck contributing toreferred paincomplexesintheshoulderarea.Theshoulder evaluationincludesageneralinspectionformuscle asymmetryoratrophy,withemphasisonthesupraspinatus region.Range of motion and muscle strength testing and generalized glenohumeral stability testing areemphasizedduringtheevaluation.TheNeerimpingement sign42 and Hawkins-Kennedy sign26 are gold standard tests to help diagnose impingement. The impingement test,whichincludes subacromialinjection ofaXylocaine-type compound and repeated impingementsignmaneuvers,ismosthelpfulinascertaining thepresenceofanimpingementsyndrome.The acromioclaVicularjointalsoisaddressedduringthe shoulder evaluation. The clinician should note acromioclavicular joint pain with direct palpation and pain on horizontal adduction of the shoulder. Selective acromioclavicular joint injection alsomay be helpful.Longhead biceps tendonpathology,including ruptures,are rare butmay occur inthissubset ofpatients.Physicalexamination willdefinethetendon's contributiontothe symptom complex. Instability testing, especially inthe youngerathleticpatient,alsoshouldbeperformed. Theclinicianshouldassessforclassicapprehension signsandperformtheloberelocationtest,recording anypositive findings. Radiographic Evaluation Standardradiographicevaluationiscarriedoutwith specialattentiontoanteroposterior(AP),30-degree caudaltiltAP,andoutletviewsoftheshoulder.24,49 These plain studies are helpful indemonstrating acromial anatomy types,hypertrophic coracoacromialligament spurring, acromioclavicular joint osteoarthrosis, andcalcifictendonitis.Theseviews,incombination withanaxillaryview,canuncoveros acromialelesions.Magnetic resonance imaging (MRI)also ishelpfulinrevealing relationships inimpingement syndrome, especiallyifrotatorcufftear andotherinternalderangement pathologies(such as glenolabraJ or biceps tendonpathologies)are suspected.7 Subacromialimpingementsyndromethathasnot respondedtorehabilitationtechniquesandnonoperativemeans mayrequiresurgery.Ifproventrials ofrehabilitation,activity modification,useofnonsteroidal antiinflammatory agents(NSAIDs),andjudicioususe ofsubacromialcortisoneinjectionsareunsuccessful, acromioplasty and subacromial decompression(SAD) shouldbeconsidered. Historically,openacromioplasties produced excellentresultsand stillhaveasignificantroleinsurgical treatment. 8.41.54Ellman 19iscreditedwiththefirstsignificant arthroscopiC SADtechniques and studies, and many surgeons and investigators have developed techniquesandarthroscopicSADadvancementsforthe surgicaltreatmentofsubacromialimpingementsyndrome.Indications for surgery to correct subacromial impingementsyndromeincludepersistentpainand dysfunction that have failedtorespond tononsurgical treatment,includingphysician- ortherapist-directed physicaltherapy,trialsof NSAIDs,subacromial cortisone or lidocaine injections, and activity modification. The most controversial surgical indication topic concerns the amount of time that should elapse before nonoperativemanagementisconsideredafailure.8 Most surgeonsandinvestigatorsrecommendatrialperiod of approximately 6months.However,this depends on theindividualpatientandpathologicconditionand shouldbetailoredtothecircumstances.Forexample, a42-year-old patient with ahistory of severalmonths ofprogressivesymptomshasanoccupationorrecreationalactivitythatrequireshigh-demand,repetitive overhead movement.Inthe absence of instability,with ahookedacromion(typeIll)andMRI-documented, partial-thickness tearing,thispatient neednot endure the6-monthtrialperiodtomeetsurgicalindications forthetreatment ofhiscondition.Ontheother hand, anoncompliantpatientinaworker'scompensationrelatedsituationwhohas aflatacromionandequivocal,inconsistent clinicalfindingsmaynevermeetthe surgicalindications. Procedure BothopenacromioplastyandthearthroscopicSAD procedure are discussed inthe follOWingsections. Open 'References 1,20,32,35, 51,55. acromioplasty techniques have beenwell documented, their outcomes have beenwellresearched,and their resultshavebeenratedasvery goodtoexcellentinnumerous studies.6.41.54 Becauseof thesefactors andthe hightechnicaldemandsofarthroscopicdecompression,surgeonsshouldnever completely abandonthis proventechnique for the surgicalmanagement of persistentshoulder impingement.Surgeonsalsomay resorttotheseopentechniquesintheeventofarthroscopicprocedurefailureorintraoperativedifficulties. Dependingonsurgicalexperienceandexpertise,an openprocedure may beused in deference toanarthroscopic SADprocedure. Arthroscopic SADforthesurgicaltreatment of impingement syndrome has a number of advantages.First, thearthroscopictechniqueallowsevaluationofthe glenohumeraljoint forassociatedlabral,rotatorcuff, andbicepspathology,aswellasassessmentofthe acromioclavicularjoint andsurgicaltreatmentof any conditioncontributingtoimpingement.Second,this techniqueproduceslesspostoperativemorbidity and isrelativelynoninvasive,minimizingdeltoidmuscle fiber detachment.However, arthroscopic SADis a technically demanding procedurewhose"learning curve" canbehigher thanforother orthopedic procedures. Manydifferentarthroscopictechniqueshavebeen described,but the authors of this chapter recommend themodifiedtechniqueinitiallydescribedbyCaspari andThaw. 14 Thepatientisusuallyanesthetizedwith both a general and a scalene block regional anesthetic. Inmost community settings this combination has been highly successfulin allowing patients to havethis procedure done on anoutpatient basis.A scaleneregional blockandhomepatient-controlledanalgesia(PCA) provideacceptablepaincontrolandensureacomfortablepostoperativecourse. After the patient has reachedthe appropriate depth of anesthesia,the shoulder is evaluated in relationship tothecontralateralsideinbothasupine andasemisittingbeachchairposition.Anyconcernregarding stability testing canbefurther assessedat this time,taking advantage of the complete anesthesia. Then,using thestandard beachchair positioning,thesurgeonbeginsthearthroscopiCprocedure.Aninflowpressure pump(Davol)isusedtomaintainappropriatetissue spacedistention.EpinephrineisaddedtotheirrigationsolutiontoaconcentrationofImg/L,thusenhancing hemostasis. Specificportalplacement isimportanttoeliminate technical difficulties. Carefully addressing the palpable bonytopographyoftheshoulderandmarkingthe acromion,clavicle,acromioclavicularjoint,andcoracoidprocessgreatlyfacilitateportalplacement(Fig. 2-1).First,thesulcusispalpateddirectly posterior to theacromioclavicularjoint.Fromthisuniversallandmark, appropriate orientation canbe obtained and con-AcromioplastyCHAPTER213 Fig.2-1.The lateralportalis fashionedonthe lateral aspect of the acromion justposterior andinferiortoaline drawnbyextendingthetopographic anatomy ofthe anterior acromioclavicular complex. sistent reproducible posterior,anterior, and lateral portalplacement achieved. Using the standard posterior portal, thesurgeon insertsthearthroscope into the glenohumeral joint.Ina routine andsequential fashion,the glenohumeral joint isevaluatedwith attentiondirectedtothebicepstendonandthelabralandrotator cuff anatomy.Anyincidentalpathology canbeaddressedarthroscopically at this point. Subacromial space arthroscopy cannow beperformed. Forsubacromialprocedures along diagnostic doublecannulaarthroscopeisrecommended.Thecannulawithblunt trocar is placed fromtheposterior portalsuperiortothecuff,exiting theanterior portal. Using this cannulaasa switchstick equivalent,the surgeonplacesacannulawithaplasticdiaphragm overthearthroscopicinstrument andreturnsit tothe subacromialspace.Gently retracting thearthroscopic cannulaandinsertingthearthroscopeallowstheinflowandarthroscopiCcannulastobeclosetogether. Adequatedistentionandmaintenanceofinflowand outflowarecrucialforvisualizationandindirecthemostasis. This technique has beensuccessful inachieving thesegoals.Atthis point thelateralportalisfashioned,generally onthelateralaspect of theacromion justposteriorandinferior toalinedrawnbyextending thetopographic anatomy of the anterior acromioclavicular complex (seeFig.2-1).A spinalneedle may assistintheaccurateplacement of thisportal,which iscrucialtoinstrumentplacementandsubsequent visualization. Startingfromtheposteriorportalandusinganaggressive synOVialresector with the inflow inthe anterior portal,thesurgeonusesthelateralportaltoperforma bursectomyanddebridethesofttissuesofthesubacromialspace.Thisisdoneinasequentialmanner, 14PartIUjjtr E;dmf.Jty working fromthe lateralbursal area to the anterior and medial acromioclavicular regions. Spinalneedles can be placedinthe anterolateraland acromioclavicular joint region to facilitatevisualization and reveal spatial relationships.Afterthesubacromialbursectomyanddenudement of the undersurface ofthe acromion, the superiorrotatorcuffcanbevisualizedalongwiththe acromioclavicular joint and anterior acromial anatomy ismore easily defined.The surgeonmust take carenot toviolatethe coracoacromialligament during thisinitialbursectomy procedure. Atthispointthesurgeoninsertsthearthroscopein thelateralportalforvisualization.Usingtheposterior portalandfollowingtheposterior slopeofthenormal acromion.thesurgeonperformssequentialacromioplastywithanacromionizerinstrument.Inthetechnique described by Caspari.14 the shank of the acromionizer is directed flat against the posterior acromial slope andacromioplastyiscompletedfromtheposteriorto the anterior aspect. This accomplishes two goals.First, it provides areliable and reprodUcible template to convert any abnormalhooked.sloped, or curved acromion tothetherapeutic goalofaflat,typeI configuration. Second, it allows fortheremovalof the coracoacromial ligament fromits bony attachment with minimal chance forcoracoacromialarterybleeding.therebymaximizingarthroscopic visualizationandminimizingtechnical difficulties.Atthis point any furthermodification or "fine tuning"may be done through both the lateraland theanterior portals.Anyresidualcoracoacromialligamentisremovedfromitsacromialinsertionwhileits bursal extensionisexcised. Theacromioclavicularjointalsomaybeassessed at this stage, andminimal inferior osteophytes may be excised.Depending ontheresults of the preoperative evaluation, distal clavicle procedures can be performed at this point either through directed arthroscopic techniques or,as the authors of this chapter prefer, through a small incisionlocated over the acromioclavicular joint region.Ifacromioclavicularjoint symptoms arepresent withhorizontaladductionanddirectpalpation, and/or ifradiographs confirmthepathology,thesurgeonshouldproceed withadistalclavicleexcision.A T-typecapsular incisionislocatedovertheacromioclavicular joint region,withthe anterior and posterior capsular leaves elevated subperiosteally fromthe distalclaVicle.Using small Homan retractors, the surgeon canexcisethedistalclavicle(usually1.5to2cm)at thispointwithanoscillatingsaw.Thedistalclavicle canthenbeeasily palpated andraspedsmooth.With asimpledigitalconfirmation,theundersurface ofthe acromion also can be checked and any residualosteophytes rasped through this minimal incision technique. Thesofttissueisthenclosedinanatomicfashion with essentially no deltoid detachment. A routine subcuticular skinclosure isused.The patient isplacedin apostoperativepouchsling,andcryotherapyisfrequentlysuggested.Thepatientisdischargedtocontinuetreatmentasanoutpatientor,ifinsuranceor health demands reqUire,overnight observation isused. Physicaltherapymaybeginimmediatelyonthefirst postoperativedayandfollowsthestandardprogram discussedinthis chapter. Outcomes . ThesurgicaloutcomesforarthroscopicSAD,partial acromioplasties,anddistalclavicleexcisions8,35have beenmostfavorable.Manystudieshavecompared open and closed techniques and obtained similar overallfindings.6,8,22SADprocedureshavethreegeneral goals: I. Toreturn the patient to apremorbid range of motionand strengthperimeters 2. Toeliminatepain 3. Toeliminatetheanatomicmechanicalcomponent ofthe impingement syndrome Challenges andPrecautions Themost commoncauses ofsurgicalfailuresareassociated withincompleteboneresectionandnotaddressing acromioclavicular joint arthropathy. Bycarefullyconsidering surgical techniques and including (if necessary)distalclavicleexcisionorcombinedopen techniques,these commonpitfallscanbe eliminated. Another common reason for failure of arthroscopic SAD surgery isinappropriate diagnosis or patient selection. Again,withcarefulassessment,especiallyregarding instability,underlyinglesions,anddifferentialdiagnoses,these failurescan be dramaticallylessened. RehabilitationConcerns:TheSurgeon's Perspective Therapists spend more time with postoperative patients thanmost surgeonsdo,andtheirinputanddirection are important in achieving asuccessful outcome. Their understanding of the procedure, postoperative pain, patient apprehension, and general medicalconcerns is vital.Physicaltherapy-directedearlydiagnosisofany woundproblems(evidencedbyerythema)or superficialinfectioncaneliminatepotentialmajor complications.Postoperative inflammation also can be assessed withcarefulobservation.Stiffnessinfrozenshoulder syndrome,althoughrare.candeveloppostoperatively andisaddressedoptimallywithearlydiagnosisand progressivephysicaltherapy. The goalofthetherapeuticexerciseprogramaftera SADprocedure istoaugment the surgicaldecompressionbyincreasingthesubacromialspace.Additional AcromioplastyCHAPTER215 Box 2-1Components of the PhysicalTherapyEvaluation -BackgroundInformation Statusof capsule Statusof rotator cuff Statusof articular cartilage Previousprocedures Associatedmedicalproblemsthat caninfluence rehabilitation(e.g.cardiovascularconcerns, diabetesmellitus) Work-relatedinjury Insurance status Motivation Comprehension Subjective Information Previouslevelof function Presentlevelof function Patient's goals and expectations Intensity of pain Locationof pain Frequencyof pain Presenceof night pain Assistance athome Accesstorehabilitationfacilities Medication(dose,effect,tolerance,compliance) clearancefor subacromialstructures canbegainedby strengthening thescapular upward rotators and humeral head depressors.Exercises to enhance the surgical decompression are straightforward. The challenge for the physical therapist is to implement the appropriate therapeuticexerciseregimenwithoutoverloadinghealing tissue. The postoperative rehabilitationprogram canbedividedinto threephases: I. Phase one emphasizes a returnof range of motion. 2.Phasetwo stresses regaining muscle strength. 3.Phasethreestressesenduranceandfunctional progression. Thesethreephasesarenot distinct entitiesandthey do overlap.Together they serveasa template onwhich thephysicaltherapist canbuild a management protocol for thepost-SAD patient.Anabsence of painistheprimary gUideline for progressing tomore strenuous activities. 13 Thephases aresimply gUidelines and shouldbe adapted to eachpatient. Patients with significant rotator cuffinvolvement,articular cartilagedefects.significant preoperativemotionorstrengthloss,perioperativeor intraoperativecomplications.andglenohumeralinstability require special consideration and may not progress as rapidly as indicated in the standard rehabilitation program,which assumes that there isno glenohumeralinstability andthattherotator cuff tendons areintact. .Objective Information Observation: Musclewasting Resting posture Useofsling Woundstatus Swelling Color Rangeof motion(active/passive): Upper thoracicspine Scapulothoracic joint Sternoclavicularjoint Acromioclavicularjoint Scapulothoracicrhythm Strength: Rotator cuff Scapular upward rotators Scapu lar retractors Scapular protractors Deltoid Biceps Signsthattherapeuticactivitiesaretooaggressive includethefollowing: Increased levels of referredpaintothe areaof insertionof thedeltoid Night pain Painthat lasts morc than 2 hours after exercising46 Painthat alterstheperformance of anactivity or exercise46 Evaluation Everyrehabilitationprogrambeginswithathorough evaluationattheinitialphysicaltherapyvisit.This evaluationprovidespertinentinformationforformulating atreatment program.Asthepatient progresses throughthe program. assessment isongoing.Activities that are too stressful for healing tissue at one point are reassessed when the tissue isready for the stress.MeasurestobeincludedinthephysicaltherapyevaluationareprovidedinBox2-1. PhaseOne TIME:First3weeksafter surgery. GOALS:Emphasisonmeasurestocontrolnormalpostoperative inflammation andpain, protect healing soft tissues,andminimize the effects of immobilization and activityrestriction(Table2-1). Table 2-1Acromioplasty RehabilitationCriteriatoProgress PhasetothisPhase PhasefaPostoperative Postoperative 1-2 days PhaseIbNo wound drainage Postoperativeor presenceof 3-10 daysinfection Anticipated Impairments and FunctionallimitationsInterventionGoalRationale Pain Edema Dependent upper extremity(usuallyin a sling or airplane splint depending on degreeof repair) Asinphasela Cryotherapy 20-30 minutes Monitoring of incision site Grip strengthexercises (with armelevatedif swollen) Continue interventionasin Phasefawith additionof thefollowing: PROMof shoulder as indicated IsometricsSubmaximaltomaximal internal andexternal rotationinsling or supported out of sling in neutralrestingposition AROM-Scapular ret racti 0 n/prot racti 0 n (position aswith isometrics) Jointmobilization to the sternoclavicular(SC)and acromioclavicular(AC) joints asindicated Decreasepain Prevent infection Minimize wrist andhand weaknessfromdisuse ImprovePROMavoiding aggravating surgicalsite Producefair togood muscular contractionof rotators Restore/maintainscapula mobility Reducepain/joint stiffness Self-managepainand manageedema Preventcomplications during healing Minimize disuse atrophy and promote circulation Increase PROMpreparing toadvanceAROM exercises Minimize reflexinhibition of rotator cuff Minimize disuse atrophy of scapulastabilizers Uselow-grade(resistancefree)mobilizations to decreasemuscle guarding and progress grades as toleratedtorestore arthrokinematics ...l. CTI "'tI 1>1~~~~~c Q' I PhaseIcComfortable out ofIntermittent pain PostoperativeslingLimitedupper 11-14 daysNo signsofextremity usewith infection or nightreaching/lifting painactivities LimitedROM Limitedstrength Continue asinPhasesla &Ib: AROM-Externalrotation (at60 0-90 0abduction) Supineflexion AROM-Supine scapular protraction(elbow extended)Mpunches side-lying (midrange) externalrotationwith support(towel)inaxilla Pronescapular retraction Pooltherapy(with appropriate waterproof dressing if incisionsite not fully closed) Cardiovascular exercise (bike,walking program) Depending onjob activities,returnto limited work duties FlexionPROMto1500 External/internalrotation PROMtofunctional levels(or fullROM) Scapulothoracic PROMto fullmObility Supine AROMflexion to1200 Symmetric AC/SC mobility Increase AROMtolerance inwater to1000 flexion Minimize cardiovascular deconditioning Improve general muscular strengthand endurance Increasecapsular extensibility withf1exion/ elevationandrotation exercises Makerotator cuff readyfor supine elevation Initiate strengthening of scapulastabilizers (prOXimalstability) Support axillatoallow for vascularsupply tocuff during exercises EncourageAC/SC accessory motions requiredforfullshoulder mobility Note that buoyant effects of water allow an environment wherethe water assists withflexion Prescribelower extremity conditioning exercisesto promotehealing and improve cardiovascular fitness Provide ergonomic educationearly toprevent future complications n o 3 o v OJif> -< ..... :::I: > ""C--l m ~N ...... .......18PartIUj}tr c,xfmdty Controlof inflammationandpain.Thesurgeonmay have prescribedNSAIDs tocontrolnormal postoperativeinflammationandpain.Thesecanbeanadjunct totheothermeansthephysicaltherapistemploysto decreaseinflammation(i.e.,gentletherapeuticexercise,cryotherapy). Thetherapistshoulddeterminewhetherascalene block wasperformedinadditiontothe generalanesthetic.If a block was performed,theonset of immediatepostoperativepainmaybedelayed,andthepatientshouldbemonitoredforsignsof delayedmotor returnand prolonged or abnormal hypesthesia. If narcoticsareusedpastthefirstfewpostoperativedays, thetherapistmust undertakethetherapeutic exercise programcautiously. Cryotherapy canbeusedto help manage postoperativepain.Crushediceconformsnicelytotheshoulder, but commercially available cryotherapy and compressionunits (PolarCare,CryocufO,although tedious touse,canbelessmessy.Sterilepostoperativeliners allow thesource of the coldto beplaced under the initialbulkydressing.Thephysicaltherapistshouldbe awareofreimbursementpracticesfortheseunits and usethemaccordingly. Protectionof healing soft tissues.Decreaseduseof the upper extremity isrequiredto protect healing soft tissuesafterSAD.Depending onthesurgeon'sprotocol andoperativefindings,a sling may beprescribed. The slinghelpsdecreasetheforcesonthesupraspinatus tendonby centralizing theheadof thehumerus inthe glenoid fossaina dependent position.Useof the sling isencouragedforthefirst2to3 days aftersurgeryin most cases,withthepatient'slevelof discomfort dictating thedegreeof slinguse. Althoughtheslingisusedtominimizepain,it can add tothe patient's discomfort. A"critical zone" of hypovascularity inthesupraspinatus tendon initially describedbyRathbunandMcNabs3 maycontributeto shoulder pain in a resting dependent position. The existence of this criticalzoneisdebated by some,but recent work by Lohr andUlthoff37 corroborates Rathbun andMcNab'sinitialfindings.This criticalzonecorrespondstotheanastomosesbetweenosseousvessels and vesselswithinthesupraspinatus tendon.Vessels inthiscriticalzonefillpoorlywhenthearmisatthe side,i2but this wringing out of thesupraspinatus tendonisnot observed whenthearmis abducted. ISIf the patient experiences increased shoulder discomfort afterprolongedperiodswiththearmattheSide,heor sheshouldplaceasmallbolster(2to3inchesindiameter)intheaxilla(restingthearminasupported, slightly abductedposition)tohelp decreasethepain. Immobilizationand restricted activities.While the sling protectsthehealingtissuearoundtheglenohumeral joint,motionshouldbeencouragedatproximaland distaljoints. Scapular protraction,retraction,and elevation canbeperformed intheSling.The patient should removethearmfromtheslingatleastthreetofour timesdailytoperformsupportedelbow,wrist,and handrangeof motion(ROM)exercises. The patient should always perform warm-up activities.Thisenhancestherateofmuscularrelaxation, increasesthemechanicalefficiencyofmusclebydecreasingviscousresistance,allowsfor greaterhemoglobinandmyoglobindissociationinthetimespent working,decreasesresistanceinthe vascular bed,increasesnerveconductionvelocity,decreasestherisk forelectrocardiographicabnormalities,andincreases metabolism.64 Thephysicaltherapistshouldeducatethepatient. Helphimorherunderstandthatdiscomfortexperiencedwithpassivestretchingintoexternalrotation comesfromthecapsuleandoccursbecausethe supraspinatusmuscleisslack. Patientswithsedentaryoccupationswhodonot havelifting duties typically canreturntowork during phaseone.Thosereturningtoworkshouldperform scapular, elbow,wrist, andhand exercises during working hours. Q Carlarrivesfortherapy5weeksaftera shoulder acromioplasty. He is having difficultyperformingshoulderflexionandscaption exercises correctly.Heoccasionally demonstrates a mild shoulder hike with arm elevation exercisesabove70degreesof elevation.How canyousequencehis exercises tomaximize his ability to elevate his arm above shoulder height? (f) PhaseTwo TIME:From3 toatleast6 weeksaftersurgery. GOALS:Emphasis onmuscle strengthening,with continuedworkonrotatorcuffmusculatureandscapulastabilizer strengthening (Table2-2). Many of theexercisesusedtostrengthentherotatorcuffandscapularstabilizershavebeenassessed byelectromyography(EMG).12EMG(bothsuperficial andfinewire)hasbeenusedtodocumentelectrical activity intherotator cuff andintrascapular musculature during the performance of various therapeutic exercises.McCannetaP8evaluatedtheEMGoutputof rotatorcuffmusculatureduringtheperformanceof morethan25commonexercisesinnormalsubjects. Exerciseswererankedfromlesstomorestrenuous basedontheamount of electricalactivity detected.A summary of theseexercisesisprOVidedinBox2-2. Musclesoftherotatorcuff(especiallythesupraspinatus)haverelativelysmallcross-sectionalareas andshortleverarms.Whenworkingwiththem,the Table 2-2Acromioplasty -AnticipatedImpairments RehabilitationCriteriatoProgressandFunctional PhasetothisPhaseLimitationsInterventionGoalRationale PhaselIaAROMto1200 LimitedreachandContinue exercisesfromPROMfullinallrangesRestoreprevious Postoperativeflexionlifting abilities.previous phases asSymmetric AROMflexionfunctionaluseandROMof 3-6 weeksAROMimprovingespecially aboveindicated:Symmetric accessoryupper extremity trendshoulderheightProgressiveresistancemotions of glenohumeralBeginstrengthening; Gait withnormalLimitedstrengthandexercises(PREs)-ElasticandSCIACjointsinternalrotators armswingendurance of armtubing exercisesforAROMflexioninstanding(subscapularis)usually Strengthof rotatorsaboveshoulder heightinternalrotationandto shoulder heightnot affectedbysurgery to 4/5(manualLimitedAROMscapular retractionwithout substitutionfromInitiate scapular retraction muscletestAtthreeweeksaddexternalscapulothoracicregionaslong lever armforces [MMTI-5/5rotationandscapularSymmetric strengthareminimal(versus normalprotractionscapulastabilizers andprotraction) Self-managepainIsotonics-Side-IyingshoulderrotatorsProgress exercisetoinclude externalrotation(withexternalrotators and axillasupport)withscapulaprotractionas '12tolibtolerancetoexercises Standing scaptionwithimproves shoulder externallyRecognizethat suprarotatedspinatusissecondary Standing shoulder flexionmover forstraight plane with112 tolibexternalrotation () a Elbow andwrist PREsStrengthenupper quarter3 with appropriatemusculature o "U weight Assesslateralscapular Accompany gravityresistedshoulder flexion l\) tr>-< slideand abduction by substi 1'"'\:J: tutionwith scapular ;l> "'tI elevation -l m ;;drtllUty 61.VoightML,OraovitchP,TippettSR:Plyometrics.InAlbert M, editor:Eccentricmuscletraining insportsand orthopaedics, ed2,New York,1995, ChurchillLivingstone. 62.VoightML,HardinjA,BlackburnTA:Theeffectsof muscle fatigueonand therelationship of arm dominance to shoulder proprioception, JOrthop SportsPhysTher 23(6);348,1996. 63.WatsonM: The refractory painful arc syndrome, J Bone Joint Surg60-B(4):544,1978. 64.Wenger HA,McFayedenR:Physiological principles of conditioning. InZachazewski IE,Magee OJ,Quillen WS,editors: Athleticinjuriesandrehabilitation,Philadelphia,1996,WB Saunders. 65.Wilk KE:The shoulder. In Malone TR,McPoil T,Nitz AJ,editors:Orthopaedicand sportsphysical therapy,ed3,StLouis, 1997,Mosby. 66.WolfWB:Shouldertendinoses,ClinSportsMed"(4):871, 1992. 67.WorrellTW,CoreyBJ,YorkSL:Ananalysis of supraspinatus EMG activity and shoulder isometric force development, MedSciSportsExerc24(7):744,1992. Cltf'Jfer3 AnteriorCapsularReconstruction Franklobe DianeSchwab CliveBrewster A lthoughit oftengoesundiagnosed,shoulderinstabilityisthecauseof shoulderpaininmany patients. J.2The frequency of instability causing shoulder pain increases with the activity levelof the patient and decreasessomewhat withage.It ismore likely in younger,moreactivepatients-especially if theyengage in overhead activities during vocational or recreationalpursuits.3 Understanding of thekineticsand root causes of shoulder pain is increasing; both factors must beaddressedtoredressthe problem. Shoulderinstability isnot anisolateddiagnosis,but rather one point ona continuumof pathology.It isoftenassociated with impingement of either the"inside" or"outside"typeandcanbefoundinpatientsof all agesandactivitylevels.Group I patients are generally older; shoulder instability is seldom found in younger patients. A subset of this group also experiences impingement of the undersurfaceof therotator cuff (Fig.3- I). GroupIIpatientsareusuallyyoungerthangroupI patients.Theyhaveinstability andimpingement,but theirimpingementissecondarytorepetitivetrauma. Thesepatientsareoftenengagedinoverheadathletic sports.Onclinical evaluation,bothrelocationandimpingementsignsareusually positive.Under anesthesia,thepass-throughsignisseenandexcessiveanteriortranslationofthehumeralheadisoftenevident. Both the anterior inferior capsule and the posterior superiorlabrumshowsignsofrepetitivetrauma;a bare spotalsomay beseenontheposterioraspectof the humeralhead.Othercommonfindingsareatearon the undersurface of thesupraspinatus or infraspinatus andlaxity in the glenohumeralligaments,especially in external rotation. Young patients with generalizedligamentous laXity fallinto group III.They toohavea positiverelocation testandinternalimpingement.Finally,groupIVpatients suffer from instability (usually subluxation, rarely dislocation) resulting from a traumatic episode. These patientsshow no evidenceof impingement.They can havea positiverelocationsign,but seldoma positive apprehension sign. Under arthroscopic examination a Bankartlesion and occasionally cartilaginous erosion of the posterior humeralheadmay benoted. Younger,moreactivepatientswithshou Iderpain andsigns of impingement canfallinto any of the four groups. Their activity demands test thelimits of strength and endurance of their shoulders. If either is insufficient. brief episodes of anterior instability follow. Associated tightnessof theposterior capsulecancontributeanotherforcevectordriving thehumeralheadforward. Thehumeralhead,now riding anterior andsuperior, causes posterior impingement andlabral pathology. If leftunchecked,theimpingementcanleadtoafrank tear of thesupraspinatus portion of the rotator cuff. Somepatientshavesignsof impingement or adiagnosis of rotator cuff tendinitis, bursitis, bicipital tendinitis. or arthritis and have been referred by anoccupational medicine clinic or a gatekeeper in a managed careoffice.Thesepatientshavepersistentpainand limitation of activity despite a course of care that may have included nonsteroidal antiinflammatory medication, other modalities (e.g.,heat, ice,ultrasound, electricalstimulation),mobilization,exercise,andrest. They may have some temporary symptom relief but no lasting change in underlying difficulties. Some of these patients havesubacromialdecompression.Evenafter surgery they may report either no improvement or that the condition is worsethanbefore thesurgery. Allshoulder pain is not caused by anterior instability.Sometimes,thepresenceof asuperiorlabralanteroposterior (SLAP)lesion complicates the clinical picture.Investigativearthroscopymaybenecessaryto determine the correct diagnosis if a conservativecare programisnot successful.Sometimespatientsreport reliefofsymptomsafterrehabilitation.Becausethey have a normal shoulder under examination, they may returntotheir normalactivitiestooearly andconsequentlyreportrecurringpainanddifficulty.Inthese instances the therapist should determine whether faulty mechanics intheir activities of choice is the culprit. It doesnot matter how well the patient's shoulder is rehabilitatedif the offending stimulus is repeated. However, when the diagnosis of anterior shoulder instabilityisthecorrectoneandismadeearly during the pathologic cou rse,as many as95%of patients can 29 30Part IUjjer c.;dmll.ity Hyperangulation - - = = = = ~ ~ PM ~ ih'A'b'l' IRehabilitation NormalII'oorJecanlcsI nterror [staI Ity I~ Anterior Subluxation Muscle Weaknessl~or Fatigue..,Stretching ofPosterror InternalImpingement Anterior Structurest undersurta;e Cuff Tear Sometimes SLAP Lesion Microtrauma ~ comPlet: Rotator Cuff Tear Fig.3-1.Instability continuum. return to their previous levelof competition.3 The later thediagnosisismadeduringthepathologiccourse, the lower the percentage of successful return with only conservative treatment. For any of these patients toreturnto their previous activities,the appropriate exercise program must be prescribed, supervised, and performed.Whilefollowingthisprogramtheauthorsof this chapter have not needed to use mobilizations,massage,or modalitiesotherthanice.Thecore groupof exercisesprotectstheanteriorshoulder,strengthens the rotator cuff, and emphasizes the scapular muscles. Details of these exercises follow.Performing them only once or twice aweek isfutile.Performing themincorrectlyisnot beneficial and may evenbe harmful.Persistence and attention todetail are both essential to a successful outcome-the elimination of pain and areturntofullactivity without surgicalintervention. Duringthiseraofcostcontainmentandrationed services,somemay feelthat thisemphasis on supervisionandperformancedetailisanunnecessaryexpenditure of medical dollars.However,by providing effectiverehabilitationthe physical therapist can relieve pain and restore function,saving medical dollars inthe long run.Ifthe therapist and patient are willing to accept lesser goals,less attention torehabilitative detail willhave tosuffice. Whendysfunctionpersistsdespitethebestefforts of orthopedist, therapist, and patient, an anterior capsulolabralreconstructionistheproceduremostlikely toeliminatepain while permitting the range of motion and strength needed forpremorbid performance.45 Traditionally,surgeonsandtherapistsbelievedthatany procedurethatrestabilizedtheshoulder(i.e.,keptit fromslipping out the front)would improve the patient's condition.Rehabilitationwasprolongedandarduous after some of the more common procedures (Bankart repair,modifiedBristowrepair).Patients weremanaged with extended immobilization forweeks or months depending on the surgeon and the procedure.Fullmotion wasseldomregainedaftersurgery.Stabilitywasreestablished, but at the expense of flexibility;patients were never able toperform at the preoperative levelagain. Inthe anterior capsulolabral reconstruction(ACLR),an axillary incisionismade 2to3cm distalandlateralto the coracoid process and extending distally into the anterior aXillary crease. The skin isundermined to provide access tothedeltoidgrooveand allow visualizationof the deltopectoral groove. This intervalisthen developed withblunt and sharp dissection.The c1avipectoralfasciaisincisedalong thelateralmarginof the conjoined tendon fromthe inferior margin of the humeral head to the coracoidprocess.Thesurgeondissectslaterally to the fleshy portion of the coracobrachialis muscle,rather than medially at the lateral border of the tendinous short headofthebiceps.Theconjoinedtendonisdissected bluntly and retracedmedially. Externalrotation of the arm brings the subscapularis intoview.Itissplitlongitudinallybetweentheupper two thirds and lower third.Afteridentifying the intervalbetweenthesubscapularisandthecapsule.the surgeonextends capsular exposuremediallyandlaterally.Theretractor should be placedunder direct visiontoavoidinjurytoneurovascularstructures.The capsuleisincisedlongitudinallyandtagsuturesare placed at the capsule margin just lateral tothe labrum. The capsu!otomy may be completed carefully down to the levelof the glenoidlabrum. The glenoidlabrumshouldbe palpated carefullyto assessforthepresenceofaBankartlesion.Thecapsule must be palpated forintegrity,volume,and ability to buttress the anterior inferior joint margin. The degree of capsular shiftmust be tailoredtothe degreeoflaxity.If aBankart lesion ispresent, it is repaired by suture fixationtothepreparedanteriorscapularneckwith Mitekbone anchors. Fig.3-2.Theinferior leadissecuredsuperiorly. Fig.3-3.The superior leadissecuredinferiorly. If thecapsuleislax or incompetent. it is overlapped toobliteratetheredundancy.Thesurgeonincisesit downtothelabrumandmedialglenoidneckforsubperiostealelevation.Theinferiorleafofthecapsule containsmostoftheinferior glenohumeralligament andisusedtoreconstructit byadvancingthetissue along the anterior glenoid rim and shifting it proximally. The superior portion of the capsule isbrought over the inferior portionandlabrum.resting along theanterior scapular neck. The reconstructionisfixedusing #2nonabsorbablesuturesfromtheMitek boneanchors.The inferior leaf is securedsuperiorly (Fig.3-2) and the superior leaf issecuredinferiorly (Fig.3-3)using a vest-Anterior CapsularReconstructionCHAPTER331 over-pantstechniquewithnonabsorbablesutures.If thelabrum is intact, it does not require removal and repair. The surgeon canSimply split the capsule and overlapit,therebyreducing thevolumeof thejoint. Theanterior glenoidlabrummaybeabsentor defective.Inthis caseor inthepresence of aBankart lesion,thecapsulemust beaffixedtothepreparedanterior scapular neck.Usually, both a capsular shift and areattachmentmust beperformed. After the capsule is closed,the surgeon takes the arm througharangeofmotiontonoteareasof tensionon the repair.Immediately after surgery,the patient may beginactivemotionwithinthiszone.Thesurgeonmust communicate with thetherapist for eachpatient toensurethatthissafezoneisobserved.Usually.avoiding abductionabove90degreesinthescapularplaneand external rotation beyond 45 degrees to90 degrees is indicated.The palmaris longus may beusedasafurther capsular reinforcement in patients with hyperelasticity. Afterdeterminingsafepostoperativemotion,the surgeonreapproximates the subscapularis.Allretractors areremovedafter a thoroughirrigation of theoperative field.Neither the deltoid nor the pectoralis musclesnormallyrequiresurgicalrepairandtheskinis closedsubcuticularly,withtheadditionofadhesive strips(Steri-Strips).Thearmissplintedinabduction andexternalrotation.Thesplintmay beremovedfor bathing and postoperative rangeof motion assessment. IfthepatienthasgeneralizedligamentouslaXity,no splint isnecessary-motion willbeeasytoreacquire. TherapyGuidelines forPostoperative Rehabilitation Because no muscles are cut inthisreconstruction procedure,rehabilitation proceeds briskly withtwo familiar general goals: I. Strengthen the dynamic glenohumeral andscapulothoracic stabilizers 2.RestorestructuralfleXibility Theprogramprimarilyconsistsofactiverangeof motion(AROM)exercisesand resistiveexercises.The therapistmustmonitortheseexercisesandenforce their correct execution for good progress to occur. This programincludes concurrent exercisesfor allparts of thetrinity of normalcy: rangeof motion, strength, and endurance.Thekeytosuccessistowork onallthree portionswithoutwaitingforcompletionofanyone part.Thetherapistshouldnotwaitforfullrangeof motion before strengthening or beoverly aggressive in pushing for allmovement early.Furthermore,the therapist should not wait for full strength before beginning endurancework.particularlyinpatientswithhyperelasticity. The best planisanintegrated one.Programs torestorestrength,motion, and endurance should overlap one another,rather thanruninsequential phases. W N tu" ....-~~~[J Table 3-1Anterior CapsularReconstruction CriteriatoAnticipated RehabilitationProgress toImpairments and Phasethis PhaseFunctionalLimitationsInterventionGoalRationale PhaseIPostoperativePostoperative painCryotherapyControlpainEducatepatient toselfPostoperativePostoperativeedemaElectricalStimulationManageedemamanagepain Iday-ZweeksDependentupperIsometrics Shoulder-allProducegood-qualityDesensitizesurgicalsite extremity (UE)inamovements inaneutralcontractionofPreventatrophy of shoulder sl