O R T H O P A E D I C S Y P M P O S I U M A P R I L 8 , 2 0 1 7

D A N I E L D O T Y M D

Shoulder and Elbow

Shoulder Articulations

�  Glenohumeral Joint ¡  2/3 total arc of motion ¡  Shallow Ball and Socket Joint

÷  Allows for excellent ROM ÷  Requires soft tissue to maintain reduction and function

�  Scapulothoracic Articulation ¡  1/3 total arc of motion ¡  No bony articulation ¡  Relies completely upon dynamic muscle function

�  Acromioclavicular joint ¡  Links the upper limb to the axial skeleton ¡  Allows for some rotational motion of the clavicle during shoulder motion

Glenohumeral Anatomy

�  Scapula: 17 Muscle Attachments

¡  Body

¡  Acromion

¡  Glenoid

Glenohumeral Anatomy

�  Labrum: Circumferential cartilage ring ¡  Deepens socket by 50% ¡  Critical role in stability ¡  Tears can result in pain and/or instability

Glenohumeral Anatomy

�  Long Head of the Biceps Tendon ¡  Questionable role in glenohumeral stability ¡  Tendonitis/ tears can result in significant pain

Glenohumeral Anatomy

�  Glenohumeral Ligaments ¡  Static stabilizers ¡  Prevent instability at the extremes of motion ¡  Tears allow for instability ¡  Inflammation results in pain/stiffness

Glenohumeral Anatomy

�  Rotator Cuff ¡  4 muscles: critical to active

function and stability ¡  Dynamic stabilizers ¡  Center the humeral head in

the glenoid throughout ROM

¡  Tears result in pain, weakness, varying degrees of dysfunction

Shoulder

�  Pathology typically affects multiple anatomic sites �  A single problem can set off a chain reaction

resulting in dysfunction throughout the shoulder girdle

�  Goals of treatment are to minimize pain while maintaining motion and function

�  Typically requires a concerted, multimodal effort by the physician, therapist, and patient to achieve a good result

Glenohumeral Arthritis

�  Destruction of Cartilage layer �  Flattening of Humeral Head �  Bone Spur/Osteophytes �  Contracture of Anterior capsule �  Loose Bodies �  Rotator Cuff Intact

Glenohumeral Arthritis

�  Physical Exam Findings ¡  Painful ROM ¡  Limited PROM=AROM ¡  External Rotation Limited ¡  Crepitus ¡  Cuff testing typically 4/5

strength

Glenohumeral Osteoarthritis

�  Nonoperative treatment ¡  Tylenol Arthritis ¡  NSAID’S ¡  Steroid Injections ¡  Activity Modification

Glenohumeral Arthritis

�  Surgical Treatment �  Anatomic Total Shoulder Arthroplasty

¡  Typically utilized for arthropathy with rotator cuff intact

Basics of Anatomic TSA

�  Surgical approach ¡  Anteriorly between Deltoid and Pectoralis Major Muscles ¡  To Access the Shoulder Joint Subscapularis Must be Released

Basics of Anatomic TSA

�  Anterior Capsule is Released to allow for Ext Rot �  Humeral Head and Glenoid are resurfaced �  Long Head of Biceps Tendon tenodesed

Basics of Anatomic TSA

�  *Subscapularis is Repaired*

Principles of Anatomic TSA Rehab

�  Respect Subscapularis repair for 6 weeks ¡  Avoid aggressive External Rotation passive stretching

÷ Limit to ER may be set by the surgeon based on intraop findings ¡  Avoid resisted Internal Rotation

�  Reinforce Patient Education and HEP

�  Maintain Pain Control and Limit Inflammation

Principles of Anatomic TSA Rehab

�  Phase I: Immediate Postop – 2wk ¡  Sling at all times other than exercises ¡  Ice ¡  Exercises 3-6 times daily

÷ Straight arm hangs ÷ Pendulums ÷ Codmans ÷ NWB Elbow, Wrist, and Hand AROM as tolerated

Principles of Anatomic TSA Rehab

�  Phase II : 2-6 weeks postop ¡  Begin outpatient PT ¡  Goal to improve PROM

÷ Supine FE stretching ÷  IR ÷ Crossbody Adduction ÷ Extension

¡  Scapular Strengthening ÷ Shoulder Shrugs and Retraction

¡  Patient may use the arm for light ADL’s, bathing, eating, etc ¡  Sling while in public

Principles of Anatomic TSA Rehab

�  Phase III : 6weeks-3months ¡  Isometrics of RC transitioning into strengthening of ABD, FE,

ER ¡  Increase resistance of shrugs, retraction, biceps and triceps ¡  Out of sling ¡  Encourage ADL’s ¡  Continue HEP

Pitfalls Postop Anatomic TSA

�  Subscapularis rupture ¡  Subscapularis is taken down and repaired in every case

÷ This is the limiting factor in post op rehab ¡  Poor tissue or repair can place at higher risk of rupture ¡  Passive external rotation places highest stress on the repair

÷ Gentle stretching in ER and nonresisted active internal rotation with limit set by surgeon is best method for the first 4-6 weeks until healing occurs

Subscapularis Failure

¡  Signs of Subscapularis Failure ÷ Painful anterior shoulder “pop” ÷ Sudden increase in Passive External Rotation ÷ Decrease in Active Internal Rotation power

¡  Management ÷ Refer back to surgeon for evaluation as soon as possible ÷ Early ruptures may be repairable ÷ Chronic ruptures with poor function or instability can be treated

with pectoralis transfer or reverse shoulder replacement

Subscapularis Failure

�  Typically results in poor outcome and may result in anterior instability and anterior superior escape

Reverse Total Shoulder Arthroplasty

�  FDA approved in US 2003 �  Originally used for rotator

cuff tear arthropathy �  Indications have expanded

rapidly and include cuff deficiency, proximal humerus fractures, revision with bone loss, chronic instability and some patterns of cuff intact arthritis

Reverse Total Shoulder Arthroplasty

�  Creates a fixed fulcrum in the shoulder �  Allows for a Constrained Joint: imparts stability

despite lack of soft tissue restraints �  Allows the Deltoid to power shoulder motion in the

absence of a functional rotator cuff

Rotator Cuff Deficient Shoulder

�  Compression lost �  Deltoid force results in sheer and superior

translation

Basics of Reverse Shoulder

�  Typically performed through anterior approach �  Often times done in the setting of a deficient

subscapularis �  Subscapularis repair/no repair has not been shown

to impact the outcome �  The operative arm will be lengthened after the

procedure and the deltoid will be stretched

Reverse Shoulder Rehab

�  Rehabilitation is similar to that of anatomic TSA but typically at an accelerated pace because there is not a need to protect the subscapularis

�  Focus is to maintain Passive range of motion and strengthen the deltoid for forward flexion and abduction

�  Retraining to allow for ADL’s �  Patients often have difficulty with active external

rotation due to loss of posterior rotator cuff

Pitfalls of Reverse Shoulder Arthroplasty

�  Periprosthetic fractures ¡  Fall prevention ¡  If good bony fixation is achieved at surgery patients can use the

implant with a walker �  Dislocation

¡  Despite constraint, instability can be a problem for reverse ¡  Avoid extension, internal rotation, adduction and axial load

÷ Typical position is reaching behind to push up out of bed or a chair or unfastening a bra

�  Acromial Stress Fractures ¡  Increased stress on acromion due to deltoid tension ¡  Pt will have point tenderness to acromion ¡  Treatment is to hold therapy and rest in a sling

Reverse for Revision, Fracture, Nonunion

�  Rehab may be slower for these situations versus RCTA

�  Fractures: Goal is to limit stiffness while protecting repaired tuberosities ¡  67 y M s/p bicycle crash with right proximal

humerus fracture

Reverse for Nonunion

•  67 yo F with a Nonoperatively treated proximal humerus fracture nonunion

Elbow Basics

�  General Elbow Principles ¡  Normal Arc of motion is 0-145 ¡  “Functional Arc of motion is 30-130, 45-45 pronation/

supination ¡  Post traumatic elbow tends to lose extension ¡  Position of stability is flexion and pronation

Elbow Basics

�  Active motion compresses the joint and typically improves stability

�  Passive motion can distract the joint �  Supine active elbow flexion and extension is a good

method to avoid distraction and work on motion �  Work on Pronation and Supination with the elbow flexed

to 90 degrees �  Work on Flexion and Extension with the forearm in

neutral or pronation �  Avoid coupled extension and supination in the early

recovery period

Elbow Case

�  30 yo F falls from 3 feet landing on outstretched arm

Radial Head Shear fracture and coronoid tip fracture indicate a fracture dislocation

Elbow Case

Intraop pivot shift test indicating rupture of the lateral ligaments resulting in posterolateral rotatory instability

�  Repair Radial Head �  Repair lateral ligament complex

Postop Management

�  Splint for 1 week �  Ice, elevate, limit swelling �  Begin ROM after 1 week

¡  Supine Active flexion and extension with forearm in neutral

¡  Pronation/Supination active and passive with elbow flexed to 90 degrees

¡  Avoid supination and full extension ¡  If needed limit extension to 30 degrees for

first 3 weeks �  Light ADL’s at 6-8 weeks postop �  Activity as tolerated 3 months

Thank You

�  Please call/text any questions about my patients