post-operative instructions shoulder arthroscopy ......rehabilitation protocol after biceps...

Laith M Jazrawi, MD

Professor of Orthopedic Surgery Chief, Division of Sports Medicine T 646-501-7223

NYU Langone Orthopedic Center 333 E 38th St, New York, NY 10016 T 646-501-7223 F 646-754-9505 www.NewYorkOrtho.com

Post-Operative Instructions Shoulder Arthroscopy, Decompression, and Biceps Tenodesis

DayofSurgery

A. Relax.Dietastolerated.B. Icingisimportantforthefirst5-7dayspost-op.Whilethepost-opdressingisinplace,icingshouldbedone

continuously.Oncethedressingisremovedonthefirstorsecondday,iceisappliedfor20-minuteperiods3-4timesperday.Caremustbetakenwithicingtoavoidfrostbite.Alternatively,CryocufforGame-readyicecuffcanbeusedasperinstructions.

YouwillbecontactedbyEastCoastOrthoticsregardinganicecompressionunittobeusedaftersurgery.Thishelpswithpainandswellingbuttypicallyisnotcoveredbyinsurance.Thecostis$200-300fora2-weekrental.Alternatively,icegelpackswithashoulderorkneesleevecanbeprovidedbythehospitalforaminimalcharge.

C. Painmedicationasneededevery6hours(refertopainmedicationsheet)

FirstandSecondPost-OperativeDay

A. ContinueIcing.B. Painmedicationsasneeded

ThirdPost-OperativeDay

A. Youmayremovesurgicalbandageandshowerthisevening.Apply4”x4”(orsimilarsize)waterproof

bandagestothesewoundspriortoshoweringandwhenshoweringiscompleteapplyfreshones.Youwillneedtofollowthisroutinefor2weeksaftersurgery.

PhysicalTherapy

A. PhysicalTherapyshouldbeginwithinthefirst10daysaftersurgery.Pleasecallyourpreferredfacilitytomakeanappointment.

*Note:Yourshoulderwillbeveryswollen.Itmaytakeaweekorlongerforthistogoaway.Itisalsocommontonoticeburningaroundtheshoulderastheswellingresolves.Ifexcessivebleedingoccurs,pleasenotifyDr.Jazrawi.Callouroffice@646-501-7223option4,option2toconfirmyourfirstpostoperativevisit,whichis

usuallyabout1-2weeksaftersurgery.Ifyouareexperiencinganyproblems,pleasecallourofficeor

contactusviatheinternetatwww.newyorkortho.com.

Dr. Laith M. Jazrawi Chief, Division of Sports Medicine Associate Professor Department of Orthopaedic Surgery

Rehabilitation Guidelines for Biceps Tenodesis

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

Theshoulderhastwoprimaryjoints.Onepartoftheshoulderblade,calledtheglenoidfossaformsaflat,shallowsurface.Thisiscoupledwiththehumerus(shapedlikeagolfball)tomakeupthejoint.Theglenoidlabrumisa”ring”ofcar@lagethatturnstheflatsurfaceoftheglenoidintoaslightlydeepersocket,whichissimilartores@ngagolfballonagolfteeinsteadofatabletop,providingmoreshoulderstability.Anotherpartofthescapula,calledtheacromium,ar@culateswiththeclavicle(collarbone)tomaketheacromioclavicular(AC)joint.Therotatorcuffisagroupoffourmuscles:thesupraspinatus,infraspinatus,teresminor,andsubscapularis.TherotatorcufftendonsaFacharoundthehumeralhead(ball)andconnectthehumerustothescapula.Thelongheadofthebicepsoriginatesfromthetopoftheglenoidfossaandlabrum(topofthegolftee).Itthenrunsthroughagrooveinthehumerus(upperarmbone)tojointheshortheadofthebicepsandinsertsonaboneintheforearm1(SeeFigure1).Becauseofitsposi@on,thelongheadofthebicepsisalsoconsideredtobeasecondarystabilizeroftheshoulderjoint.Thelongheadofthebicepsisatriskofinjuryanddegenera@vechangesduetoitsproximitytotherotatorcuffandtheacromium.Sincethelongheadofthebicepscanactasasecondarystabilizeroftheshoulder,itisalsosubjecttoinjuryduringhighspeedoverheadmovements;repe@@veoverheadmovements;orforcefulshoulderac@vi@eswhentheelbowisstraight.Specificinjuriesmayincludeinflamma@onandirrita@onofthebiceptendonitself;aproblemwiththebiceptendoninconjunc@onwithoneoftherotatorcufftendons;ordetachmentofpartofthetendonfromtheaFachmentpoint(SLAPtear).1Biceptendondegenera@onand/ortearingcancausesignificantshoulderdiscomfortanddysfunc@on(SeeFigure2).Abicepstenodesisisasurgicalprocedurewhichmaybeperformedfortreatmentofseveresymptomsinvolvingthebicepstendon,includinginflamma@onorpar@altears.Itmaybeperformedinisola@onoraspartofalargershouldersurgery,includingsurgeryinvolvingtherotatorcuff.Duringthebicepstenodesis,thenormalaFachmentofthebicepstendonontheshouldersocket(glenoidfossa)iscutandreaFachmentofthetendonismadeonthehumerus(upperarmbone).ThistakesthepressureoffthebicepsaFachmentandplacestheaFachmentbelowtheactualshoulderjoint.2Thegoalistoeliminatetheshoulderpaincomingfromthebiceptendon.Differenttechniquesareusedtoperformabicepstenodesis.Thesurgicaltechniquescanbebrokendownintotwocategories:soV@ssuetechniquesandhardwarefixa@ontechniques.Bothtechniquesareeffec@veandchosenbasedonsurgeonpreferenceandpa@entindica@ons.

Figure1Shoulderanatomy

Rehabilitation Protocol After Biceps Tenodesis

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

TheprimarysoV@ssuetechniqueisthe“openkeyholeprocedure”.AnopenkeyholetechniquerelocatesthetendonwithinthegrooveinthehumerusboneaVercuXngitfromitsoriginalloca@onintheshoulder.1Theprocedureinvolvestheproximalend(thepor@onclosesttotheitfromitsoriginalloca@onintheshoulder.)ofthebicepstendonbeingrolledintoaballandthensuturedtogetherasamass.Akeyholeismadeinthegrooveofthehumerus,thetendonmassistheninsertedintothekeyholeandpulleddownwardsothatthetendonmassislockedinplace.3ThePiFtechniqueusestwoneedlestopiercethebiceptendoninoppositedirec@ons.Suturesarethenthreadedthroughtheneedlestomakeasuture.ThisprocedureisrepeatedwiththeneedleplacementreversedtocreatealockingpaFernofthesutures.Aknotisusedtosecurethesuturestothetransverseligamentintheshoulderinsteadoftothebone.4Thehardwarefixa@ontechniquesincludescrewfixa@onorendobuFonfixa@on.Inthescrewfixa@onthetendonisdetachedandthenplaceinaholemadeatthetopofthebicipitalgroove.Thenaninterferencescrewisplacedoverthetendon,intothebone,toholditinplace.IntheendobuFontechniquethereleasedtendonissecuredtoabuFon,thebuFonisthensecuredbehindthebonebyslidingitintoasmallerholeatthetopofthebicipitalgroove.Imagineadrywalltypeanchorwherethepressureisappliedfromtheinsideout.Appropriaterehabilita@onisvitaltoop@mizingyouroutcomeaVersurgery.Therehabilita@onguidelinesaretailoredtothetypeofprocedureperformed,thereforebelowyouwillfindrehabilita@onguidelinesforsoV@ssuefixa@ontechniquesandrehabilita@onguidelinesforhardwarefixa@ontechniques.Therehabilita@onguidelinesarepresentedinacriterionbasedprogression.General@meframesaregivenforreferencetotheaverage,butindividualpa@entswillprogressatdifferentratesdependingontheirage,associatedinjuries,pre-injuryhealthstatus,rehabilita@oncomplianceandinjuryseverity.Specific@meframes,restric@onsandprecau@onsmayalsobegiventoprotecthealing@ssuesandthesurgicalrepair/reconstruc@on.

Figure2aNormallongheadofbicep.Themusclehasasmootharcfromtheshouldertotheelbow

Figure2bandFigure2cTornlongheadofbicep.Themusclehasretractedtowardtheelbow

Rehabilitation Protocol After Biceps Tenodesis

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

Goal o  Sling immobilization to be worn at all times for showering and rehab under guidance of PT

o  Goals: full passive flexion/extension at elbow and full shoulder AROM

Range of Motion o  PROMàAAROMàAROM of elbow as tolerated without resistance (allows biceps tendon to heal into new insertion on the humerus without being stressed), AROM of shoulder (no restriction )

o  Encourage pronation/supination without resistance

Therapeutic Exercises

o  Grip strengthening o  Heat/Ice before and after PT sessions

Goals o  Discontinue sling immobilization

Range of Motion Exercises

o  Being AROM of elbow with passive stretching at end ranges to maintain/increase elbow/biceps flexibility

Therapeutic Exercises

o  Begin light isometrics with arm at side for rotator cuff and deltoid – can advance to bands as tolerated

o  Begin light resistive biceps strengthening at 8 weeks

Phase I (Surgery to 4 weeks after surgery)

Phase III (4 to 12 weeks following surgery)

Range of Motion Exercises

o  Progress to full AROM of elbow without discomfort

Therapeutic Exercises

o  Continue and progress with Phase II exercises o  Begin UE ergometer o  Begin sport-specific rehabilitation o  Return to throwing at 3 months o  Throwing from a mound at 4.5 months o  Return to sports at 6 months if approved

Rehabilitation Protocol After Biceps Tenodesis

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

References 1.KruppRJ,KevernMA,GainesMD,KotaraS,SingletonSB.LongHeadoftheBicepsTendonPain:Differen@alDiagnosisandTreatment.JourOrtho&SportsPT.Feb2009;39(2):55-70.2.RomeoAA,MazzoccaAD,TauroJC.ArthroscopicBicepsTenodesis.Arthroscopy.Feb2004;20(2):206-213.3.OzalayM,etal.MechanicalStrengthofFourDifferentBicepsTenodesisTechniques.Arthroscopy:JourArthro&RelatedSurg.Aug2005;21(8):992-998.4.Lopez-VidrieroE,Cos@cRS,FuFH,RodoskyMW.BiomechanicalEvalua@onof2ArthroscopicBicepsTenodesis:Double-AnchorVersusPercutaneousIntra-Ar@cularTranstendon(PITT)Techniques.AmJourSportsMed.2010;38(1):146-152.5.SlenkerNR,LawsonK,CiccoXMG,DodsonCC,CohenSB.Bicepstenotomyversustenodesis:clinicaloutcomes.Arthroscopy.2012Apr;28(4):576-82.doi:10.1016/j.arthro.2011.10.017.Epub2012Jan28.6.BurnsJP,BahkM,SnyderSJ.Superiorlabraltears:repairversusbicepstenodesis.JShoulderElbowSurg.2011Mar;20(2Suppl):S2-8.doi:10.1016/j.jse.2010.11.013.

Laith M Jazrawi, MD

Professor of Orthopedic Surgery Chief, Division of Sports Medicine T 646-501-7223

NYU Langone Orthopedic Center 333 E 38th St, New York, NY 10016 T 646-501-7223 F 646-754-9505 www.NewYorkOrtho.com

Rehabilitation Protocol: Biceps Tenodesis Name:____________________________________________________________Date:_________Diagnosis:_______________________________________________________DateofSurgery:______________________

PhaseI(Weeks0-4)• SlingimmobilizationtobewornatalltimesexceptforshoweringandrehabunderguidanceofPT• RangeofMotion–PROMàAAROMàAROMofelbowastoleratedwithoutresistance(allowsbiceps

tendontohealintonewinsertiononthehumeruswithoutbeingstressed),AROMofshoulder(norestriction)

o Goals:fullpassiveflexion/extensionatelbowandfullshoulderAROMo Encouragepronation/supinationwithoutresistanceo Gripstrengthening

• Heat/IcebeforeandafterPTsessions

PhaseII(Weeks4-12)• Discontinueslingimmobilization• RangeofMotion

o BeginAROMofelbowwithpassivestretchingatendrangestomaintain/increaseelbow/bicepsflexibility

• TherapeuticExerciseo Beginlightisometricswitharmatsideforrotatorcuffanddeltoid–canadvancetobandsastoleratedo Beginlightresistivebicepsstrengtheningat8weeks

• ModalitiesperPTdiscretion

PhaseIII(Months3-6)• RangeofMotion–ProgresstofullAROMofelbowwithoutdiscomfort• TherapeuticExercise

o ContinueandprogresswithPhaseIIexerciseso BeginUEergometero Beginsport-specificrehabilitationo Returntothrowingat3monthso Throwingfromamoundat4.5monthso Returntosportsat6monthsifapproved

• ModalitiesperPTdiscretionComments:Frequency:______timesperweek Duration:________weeksSignature:_____________________________________________________Date:___________________________