Systematic rehabilitation should be performed after rotator cuff injury, whether after surgical or non-surgical treatment. All rehabilitation training should be completed under the guidance of a rehabilitation therapist. Post-operative rehabilitation training mainly includes patients wearing shoulder slings after surgery, and the time of removal is subject to the clinician’s opinion.
1.Disease Introduction
The rotator cuff consists of the tendons of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, attached to the edges of the greater tuberosity of the humerus and the anatomical neck of the humerus, with its inner surface closely connected to the joint capsule and the subdeltoid bursa on the outside. It surrounds the upper end of the humeral head, which can incorporate the humeral head into the glenoid, stabilize the joint, assist in shoulder abduction, and has a rotational function. The supraspinatus muscle is attached to the uppermost part of the greater tuberosity of the humerus and is often worn by the rostral-shoulder ligament of the acromion, which is a weak point of the rotator cuff in terms of anatomical structure and mechanical stresses. When the shoulder joint does abrupt induction activities in the external booth, it is prone to rupture, and the gravity of the limb and the pulling of the rotator cuff make the rupture bigger and bigger, and it does not heal easily [1].
Etiology
It is usually seen in men over 40 years of age, and in young people, most of them have a history of severe trauma. Since the rotator cuff is protected by the acromion, direct violence rarely causes rotator cuff rupture. Indirect violence is mostly due to the degenerative changes of the rotator cuff with age and the abduction of the upper limb and the sudden inversion of the palm of the hand, especially because of the weakness of the supraspinatus muscle, which is subjected to the greatest pulling force and is therefore prone to rupture, accounting for about 50% of cases.
Rotator cuff injuries can be divided into two categories, partial rupture and complete rupture, depending on the degree of rupture. If not handled properly, partial rupture can develop into complete rupture.
Diagnosis
(A) Clinical manifestations
When the rotator cuff is ruptured, the patient often feels a tearing sound, local swelling, subcutaneous bleeding, local pain is limited to the top of the shoulder and spreads to the deltoid stop, and the pressure pain between the large node and the shoulder peak is obvious.
(B) Physical signs
The size of the rotator cuff rupture can be determined according to the size of the pressure pain. If the local pressure point is closed with 1% procaine and the patient can actively abduct the shoulder joint after the pain disappears, it indicates that the rotator cuff is not ruptured or is only partially ruptured; if it cannot be actively abducted after closure, it indicates a serious rupture or complete rupture.
2. Popping: When the rotator cuff rupture passes under the acromion, it pops, especially if the rupture is complete.
3. Pain arc: pain occurs within 60° to 120° of shoulder abduction in partial rupture.
4.Fracture: In complete rupture, the ruptured fracture can be felt.
5.Muscle atrophy: In the early stage, it is not obvious because of the abundant deltoid muscle covering, but in time, the same supraspinatus and infraspinatus muscles become uselessly atrophied, especially the infraspinatus muscle is obvious. Sometimes the deltoid muscle is not only atrophied but also enlarged.
6. Abnormal joint activity: When the rotator cuff rupture is large, the affected arm cannot be abducted and is replaced by shoulder shrugging activity. Due to the rotator cuff rupture, the contraction of the deltoid muscle and the upward movement of the humerus along its vertical axis force the scapula to slide and rotate on the chest wall, resulting in abnormal shoulder joint activity and a weakening of the resistance to abduction.
7.Upper arm droop test: After testing the local anesthesia, the upper arm on the affected side is passively abducted to 90°. If the affected limb can maintain this position without support, it indicates that there is no serious injury to the rotator cuff; if the passive abduction position cannot be maintained, it indicates a serious or complete rupture of the rotator cuff.
(C) Auxiliary imaging tests
1.X-ray examination: It is not specific for diagnosis, but it can help to identify and exclude shoulder fracture, dislocation and other bone and joint disorders.
2.CT tomography: It is not significant for the diagnosis of rotator cuff lesions. In case of extensive rotator cuff tears with glenohumeral instability, it can help to detect abnormalities in the anatomical relationship between the shoulder glenoid and the humeral head and the manifestation of instability.
3, ultrasonography: the advantages are non-invasive, dynamic observation, repeatability, high accuracy, ability to detect rotator cuff tears other than supraspinatus; easy to operate, time-saving and low cost; able to make a diagnosis of biceps longus tendon lesions at the same time; has its unique value for postoperative follow-up of rotator cuff tears and its diagnostic accuracy rate is 90%.
4.Magnetic resonance and magnetic resonance arthrography: MRI is currently the most effective imaging method to examine rotator cuff injury. MRI can show all stages of rotator cuff injury through abnormal response of morphology and signal. Magnetic resonance arthrography is an intra-articular injection of an iodine-containing contrast agent via the joint capsule under fluoroscopy. Due to the expansion of the joint capsule, small rotator cuff tears are more clearly shown under the contrast agent, and the accuracy rate of MRI arthrography is over 90%.
5. Arthroscopy: In recent years, arthroscopy has been considered the “gold standard” for diagnosing partial rotator cuff tears, and is mainly used in some cases where diagnosis is difficult [2].
Differential diagnosis
1. Dislocation of shoulder fracture.
2. Rupture of the long head of the biceps tendon, with the rupture mostly located in the intertrochanteric groove. In acute traumatic rupture, there is severe pain and weakness in flexion of the elbow. In chronic rupture, the flexion force of the elbow gradually decreases. The resistance flexion elbow test is weak or the pain is increased.
3. Stretched shoulder [3].
Staging and treatment
(I) Staging: Neer (1972) divided rotator cuff injury into stage III: stage I for age <25 years, reversible lesions, shoulder pain during activity to pain during activity, punctate tenderness in the suprascapular region, with painful arcs, and increased pain with resistance; stage II for age 25-40 years, chronic tendinitis caused by repeated trauma, persistent shoulder pain, often aggravated at night, signs similar to stage I but heavier; stage III includes Stage III includes complete tendon rupture, bony changes, age 40 years or older, long history of disease, mild shoulder pain to severe shoulder pain, more severe at night. The range of motion of the shoulder can range from normal to severely restricted, and passive activity is greater than active activity.
(ii) Choice of treatment method.
Clinical treatment should be based on the degree of rotator cuff tear and the patient’s specific situation
1.Non-surgical treatment: It is suitable for Neer stage I, especially for partial rotator cuff tears less than 3 months after injury, complete tears that do not want to receive surgical treatment, and elderly patients, who should be treated with analgesic, hemostatic, dehydrating, and blood-activating drugs. Most of them can receive good results.
2.Surgical treatment: If the non-surgical treatment does not restore the abduction of the shoulder joint in 4-6 weeks, surgical treatment should be considered. Surgery is suitable for complete rotator cuff tears and partial rotator cuff tears that are unsatisfactory with non-surgical treatment. For complete rotator cuff tears, the surgical approach should be to re-fix the tendon-bone in the area of the original tendon attachment and firmly close it with non-absorbable sutures; for partial rotator cuff tears, surgery is recommended to repair the rupture site with anastomosis.
Rehabilitation Training Editor
After rotator cuff injury, whether after surgical or non-surgical treatment, systematic rehabilitation training should be conducted. All rehabilitation training should be completed under the guidance of a rehabilitation therapist.
Postoperative rehabilitation: Patients wear a shoulder sling after surgery, and the time of removal is subject to the clinician’s opinion.
The treatment program is divided into three phases
Phase I (0~6 weeks postoperatively).
A considerable degree of contracture will occur with 4 weeks of braking of the normal joint, while 2 weeks of braking of the injured joint will result in fusion of connective tissue fibers and loss of joint motion function. If swelling is not treated promptly and continues for more than 1-2 weeks, it will inevitably aggravate local adhesions and limit functional activities. Therefore, we ask patients to apply ice to the shoulder to reduce swelling and increase the pain threshold, while actively moving the hand, wrist and elbow, elevating the affected limb, and passively moving the shoulder to reduce adhesions for 0-6 weeks. The shoulder sling should be used in a comfortable position for 0-3 weeks postoperatively for protection and should not be used for weight bearing or excessive force. Otherwise, it will affect the functional recovery of the tissue healing agent. The duration of shoulder sling protection depends on the pain and muscle strength.
1.Circle and pendulum: the healthy hand assists the affected upper limb to do back and forth, left and right swing and clockwise and counterclockwise circles.
Pendulum movement, also known as Codman’s movement, is a method of self-relaxation of the shoulder joint. The body is bent forward (stooped) until the upper body is parallel to the ground, and the arm is swung under the protection of the triangular scarf and the hand on the healthy side. The first is in the anterior-posterior direction, and after adapting to the basic painlessness, increase the left and right lateral ones, and finally increase the circular (drawing circle) movement, gradually increasing the range of motion, but not exceeding 90°.
2. Exercises for adjacent joint movements of the hand, wrist, forearm and elbow (active); all 3 times/d, 5 to 10 times/time.
Hand: grasping, stretching
Wrist: palmar flexion, dorsiflexion, ulnar deviation, radial deviation, circular rotation
Forearm: anterior rotation, posterior rotation
Elbow: flexion, extension
3. cold compresses on the painful area, 3~6 times/d, 20–30min each time.
4.Passive activity exercises, passive activity of shoulder joint forward flexion and body side external rotation starting on the 1st postoperative day, passive activity of shoulder joint abduction, internal rotation and abduction external rotation starting on the 3rd~4th postoperative day.
Shoulder anterior flexion: The patient should lie flat on the bed, straighten the upper arm on the affected side, and hold the elbow of the affected limb with the healthy hand. Without exerting force on the affected limb, the healthy hand should exert force to lift the affected limb to the maximum angle possible and maintain it at that angle for 1 minute.
Shoulder lateral external rotation: The patient lies flat on the bed. The affected elbow is flexed at 90° and held close to the side of the body. A wooden stick is held against the palm of the affected hand by the able-bodied hand. While maintaining the affected elbow joint firmly against the body side, push the affected hand outward as far as possible, and maintain the same for 1 minute when the maximum limit is reached.
Shoulder abduction: The patient should lie flat on the bed, hold a wooden stick with both hands in front of the body and push the affected side towards the body, so that the upper limb of the affected side is pressed against the bed and the shoulder joint is unfolded, maintaining the same for 1 minute when the maximum is reached.
Shoulder abduction and external rotation: The patient should lie flat on the bed, the affected elbow joint should be flexed at 90°, the elbow should not be close to the body side, the affected shoulder joint should be abducted as far as possible, within 90°, 90° is the best, both the healthy hand and the affected hand should hold one end of the wooden stick, the healthy hand should push the affected hand outward as far as possible, pay attention to the upper arm should not leave the bed surface, maintain the same for 1 minute when reaching the maximum.
Internal rotation of the shoulder joint: The patient stands in a standing position with the affected arm behind the back and the healthy hand behind the head. The ends of a towel are held in each hand. Without exerting any force on the affected limb, the affected hand is pulled upward by the towel held by the healthy hand as far as possible and maintained for 2 minutes when the maximum limit is reached.
5, 2 weeks after the removal of the stitches after surgery for deltoid isometric contraction training: exercise the anterior, middle and posterior parts, respectively, all 3 times/d, 5~10 times/time.
Isometric contraction: muscle in contraction its length remains the same while only tension increases, this contraction is called isometric contraction, also known as static contraction.
Isometric contraction training of the deltoid muscle: The patient lies flat on the bed. The affected hand is held in a fist with the elbow joint flexed at 90° and pressed against the side of the body. While keeping the body, shoulder joint, and upper limb position immobile, perform anterior, lateral, and posterior resistance training. The resistance object can be bed, healthy hand, and wall, etc.
Phase II (7~12 weeks).
1.In addition to the sling after the active auxiliary joint activity training: shoulder ladder, pulley, etc.
2.Use sticks etc. in standing position for forward flexion, abduction, external rotation etc. for 7-12 weeks, all 3 times/d, 5~10 times/time; in standing position, hold sticks with both hands, the healthy hand drives the affected hand to perform the exercises.
3.Continue shoulder muscle isometric contraction exercises; this phase of training can be performed with the standing position, however, the principle of keeping the trunk, affected shoulder and upper limb immobile should be maintained
4.Posture correction; maintaining good habits and posture in daily life is as important as rehabilitation training. Both can help rehabilitation training well and avoid unnecessary complications.
①Sleep
If the quality of sleep is good and there is no pain when you wake up, then do not change your habits. If you have shoulder discomfort while sleeping, then avoid moving your head with the affected limb resting on it, as that is not good for circulation. Also, you can use multiple pillows to keep the limb slightly abducted
② Avoid holding the upper extremities above the shoulder level in the early stage of daily living activities. When working for a long time or holding heavy objects, keep the elbow joint bent and close to the body. Try to use foot pads or small benches when lifting overhead to get things
③Posture training.
a.Take in the lower jaw while extending the scapula backward in sitting or standing position, take in the lower jaw, while extending the scapula backward and downward, avoid forward bending or extending the neck backward, keep the gaze to the front.
b. Active forward flexion of the shoulder joint and keep the upper trapezius muscle relaxed: raise the upper limb forward and keep the shoulder joint relaxed, avoid shrugging the shoulder. You can train in front of a mirror or place the opposite hand on the shoulder.
5. Daily life movement training (hair combing, bathing, etc.). Before training, you can apply hot compresses and start training after the muscles are relaxed. Note: The affected side should not bear weight, do not repeat the action quickly and repeatedly, and try to use the affected side for daily activities.
Stage 3 (after 12 weeks).
At this stage, the reconstructed or repaired rotator cuff has basically healed, so in addition to continuing to strengthen the previous movements, you can perform terminal pulling and strength exercises 12 weeks later (3 sheets).
a. Shoulder joint pulling in all directions using doors, tables, etc., 3 times/d, 5~10 times/d, each need to last 10~20s.
a. Door frame pectoral muscle pull training upper arm abduction, bend elbow forearm placed in the door frame. Slowly turn the trunk to the opposite side until you feel the pulling sensation of the pectoral muscles.
b.Posterior shoulder traction training with the shoulder joint in the horizontal plane of 90 degrees of pronation, with the opposite hand at the elbow joint adding force to help the traction.
c.Shoulder anterior flexion traction training standing position facing the wall, hands slide upward and slowly approach the wall to increase traction.
②Use dumbbells, elastic bands, etc. to perform strength exercises in all directions, 2-3 times/d, 15 pcs/time, need to last 5- 10s when reaching the end point. the following are a few key contact movements to maintain the balance of shoulder joint muscle strength.
a. Shoulder joint body side resistance internal and external rotation training hold one end of an elastic band in your hand, the other end of the band is fixed somewhere, pull the band with force to the outside. Hold it at the maximum angle for a certain time or complete the movement once. The amount of resistance can be adjusted by the tightness of the band.
b. Shoulder joint resistance back extension training hand hold one end of the elastic band, the other end of the band is fixed at a certain place, pull the band backward with force. Hold it at the maximum angle for a certain period of time or complete the exercise. The amount of resistance can be adjusted by the tightness of the band.
c. Shoulder joint resistance forward bending training hand holding an elastic belt end, the other end of the belt stepped on the foot, pull the belt upward with force. The amount of resistance can be adjusted by the elasticity of the band. Be careful not to shrug your shoulders and keep your thumbs up.
Compound exercise training: Patients can be allowed to swim, jog and play ball games to restore the coordination and accuracy of the upper limbs, but no competition sports can be performed within six months.
All activities should be within the range of pain tolerance during training. Physical therapy and medication can also be used to control inflammation and reduce pain.