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Document Text Contents
Page 1

One Line Academy White.eps


W. Ben Kibler, MD: Editor

Knowledge
Update

Orthopaedic

Sports Medicine

American Orthopaedic
Society for Sports Medicine

Product No. 02989
ISBN: 978-0-89203-575-5

Kibler

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Page 2

Two Line Academy 1c.eps


Knowledge
Update:
Sports Medicine

Orthopaedic

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In addition, levels of muscular activation during
Codman’s pendulum exercise have been quantified.4

Minimal levels of muscular activation have been de-
tected in the rotator cuff musculature during Codman’s
pendulum exercise; however, the exercise cannot be
considered passive because the musculature is truly ac-
tivated, especially in individuals with shoulder pathol-
ogy. Muscular activity in the rotator cuff musculature
was not changed between the performance of pendu-
lum exercise with and without weight applied.4 Pendu-
lum exercises without weight applied have the same ef-
fect on muscular activity as weighted exercises,
questioning the use of pendulum exercises in the early
period after surgery when only passive movements may
be indicated.

Rehabilitation in the first 2 to 4 weeks following ro-
tator cuff repair typically consists of passive exercise as
well as several minimally active or active assisted exer-

cises for the rotator cuff (such as active assisted
elevation, overhead pulleys, and pendulums). Addition-
ally, the balance point position (90° of shoulder flexion)
may be used while the patient is supine. The patient is
queued to perform small active motions of flexion/
extension from the 90° starting position to recruit rota-
tor cuff and scapular muscular activity. These exercises,
coupled with early scapular stabilization via manual re-
sistance techniques emphasizing direct hand contacts on
the scapula to bypass force application to the rotator cuff
and optimize trapezius, rhomboid, and serratus anterior
muscular activation, are recommended (Figure 1). Elec-
tromyogram quantification of low-level closed chain
exercise such as weight-shifting on a rocker board was
studied, and the low levels (< 10%) of activation of the
rotator cuff and scapular musculature during applica-
tion were highlighted.5

The effects of simulated active range of motion on
the integrity of a cadaveric supraspinatus repair per-

Table 1

Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair (Medium- Sized Tear)
(continued)

Postoperative Week 8:
1. Begin closed chain step-ups and quadruped rhythmic stabilization exercise.

2. Initiate upper extremity plyometric chest passes and functional two-hand rotation tennis groundstroke or golf swing
simulation using small exercise ball and progressing to light medicine ball as tolerated.

Postoperative Week 10:
1. Initiation of submaximal isokinetic exercise for IR/ER in the modified neutral position. Criterion for progression to isokinetic

exercise:

a. Patient has IR/ER ROM greater than that used during the isokinetic exercise.

b. Patient can complete isotonic exercise program pain-free with a 2- to 3-lb weight or medium resistance surgical tubing or
elastic tubing.

2. Progression to 90° abducted rotational training in patients returning to overhead work or sport activity.

a. Prone ER.

b. Standing ER/IR with 90° abduction in the scapular plane.

c. Statue of Liberty exercise (ER oscillation).

Postoperative Week 12 (3 Months):
1. Progression to maximal isokinetics in IR/ER and isokinetic testing to assess strength in modified base 30/30/30 position. Formal

documentation of AROM, PROM, and administration of shoulder rating scales.

2. Begin interval return programs if criteria have been met:

a. IR/ER strength minimum of 85% of contralateral extremity.

b. ER/IR ratio 60% or higher.

c. Pain-free range of motion.

d. Negative impingement and instability signs during clinical examination and formal physical therapy to home program
phase.

Postoperative Week 16 (4 Months):
1. Isokinetic re-evaluation, documentation of AROM, PROM, and shoulder rating scales.

2. Progression continues for return to full upper extremity sport activity (such as throwing, or serving in tennis)

3. Preparation for discharge from formal physical therapy to home program phase.

ROM = range of motion; AROM = assisted range of motion; AAROM = active assisted range of motion; PROM = passive range of motion; IR = internal rotation; ER = external
rotation

Chapter 18: Rehabilitation Principles Following Rotator Cuff and Superior Labral Repair

219American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Sports Medicine 4

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formed using either transosseous tunnels or suture an-
chors has been studied.6 Results showed no difference
between repair constructs following repetitive loading,
indicating the ability of an arthroscopically based su-
ture anchor fixation model to withstand active loading
in a manner similar to transosseous repair used during
mini-open and open rotator cuff repair.

Resistive Exercise (Strengthening Progression)
The progression to resistive exercise for the rotator cuff
and scapular musculature is variable, typically occur-
ring approximately 6 weeks after surgery when early
theoretic healing is assumed in the repaired tissues.7-9
This progression is based on several factors, such as
tear size, tear type, tissue quality, concomitant surgical
procedures, patient health status, and age. Communica-
tion between the referring surgeon and the physical
therapist is critical to share information regarding fixa-
tion limitations, tissue challenges, and/or other con-
comitant relative factors that would limit the progres-
sion of postoperative rehabilitation.

The clinical application of resistive exercise during
this critical stage of rehabilitation is guided by the level
of muscular activity within the individual muscles of
the rotator cuff and scapular stabilizers as well as the
patient’s demonstrated exercise tolerance.10-18 These
factors help determine optimal exercise movement
patterns to produce the desired level of muscular acti-
vation in the rotator cuff and scapular stabilizers (Fig-
ure 2). Repetitive low-resistance exercise is recom-
mended both for safety and relative protection of the
repaired tissues and to improve local muscular endur-
ance. Multiple sets of 15 to 20 repetitions have been
shown to improve muscular strength in the rotator cuff
and scapular stabilizing musculature.19-21 Exercise pat-
terns using shorter lever arms and maintaining the gle-

nohumeral joint in positions less than 90° of elevation
and anterior to the coronal plane of the body are theo-
rized to reduce the risks of both compressive irritation
and capsular loading/attenuation during performance.22
Additionally, early focus on the rotator cuff and scapu-
lar stabilizers without emphasis on larger prime mover
muscles such as the deltoid, pectorals, and upper trape-
zius is recommended to minimize unwanted joint shear
and inappropriate arthrokinematics and optimize
external/internal rotation muscle balance.21,23,24 The in-
herent advantages of using low-resistance exercise
strategies to target the infraspinatus during external ro-
tation exercise have been studied.24 External rotation
exercise using a 40% maximum voluntary isometric
contraction (MVIC) reportedly is superior to higher
loads in preferentially recruiting the infraspinatus mus-
cle over conditions with higher MVIC loading. In-
creased loading leads to a relative increase in the
amount of middle deltoid muscle activation.

One specific exercise that has been described exten-
sively in the literature is the empty can exercise (scapu-
lar plane elevation with an internally rotated [thumb
down] extremity position). Although electromyo-
graphic studies have shown high levels of activation of
the supraspinatus during the empty can exercise,14,16,25
the combined movements of elevation and internal ro-
tation have produced clinically disappointing results in
practical application as well as the common occurrence
of patterns of substitution and improper biomechanical
execution in patients. These compensations have been
objectively quantified, and increases in scapular inter-

Figure 1 Scapular stabilization exercise used in rehabilita-
tion following rotator cuff and labral repair.
Manual resistance applied by the physical thera-
pist targets the early activation of the serratus
anterior, trapezius, and rhomboid muscles and is
used throughout the rehabilitation process.

Figure 2 Exercises applied to strengthen the rotator cuff
based on electromyographic research.

Section 4: Rehabilitation

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American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Sports Medicine 4 459

Index

Valgus stress test, 49, 49f
Valsalva maneuver, 83, 359t
Varicella zoster virus, 375
Varus malreduction, 10
Varus stress, 41, 181
Vascular endothelial growth factor, 308t,

309, 310
Vascular remodeling, 309
Vasovagal reactions, 83
Vastus lateralis, 86, 247
Ventricular fi brillation, 361–362
Ventricular hypertrophy, 360
Verruca vulgaris, 375
Viral infections, 371

diarrhea, 370
in the eye, 366
skin infections, 374–375

Viscosupplementation therapy,
166, 167

Volitional exercise, 248–249

W
Wafer procedure, 75
Walking lunge, 267, 267f
Warts. See Verruca vulgaris
Weaver-Dunn procedure, 7
Wedge resection, 85
Weight-bearing exercises

for articular cartilage lesions, 161
after autologous chondrocyte

implantation, 258
core stabilization and, 265
after microfracture, 259, 260
after osteochondral autograft

transplantation, 257
for plantar fasciitis, 187
rehabilitation and, 247, 249–251, 275,

276
for trochlear groove defects, 261

Wilson sign, 156

Wolff-Parkinson-White syndrome,
361

Workouts, nutritional requirements for,
349–350

Wrist. See also under Hand
cartilage injuries, 76–77
extensor carpi ulnaris injuries, 77
imaging of, 436–437 (See also under

the various imaging techniques)
Kienbock disease, 393–394
ligamentous injuries, 76
pathology of, 74–75

Y
Youth athletes. See Athletes

Z
Z-plasty, 87

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Page 469

B&J USA 2002-2011 white copy.eps


W. Ben Kibler, MD: Editor

Knowledge
Update

Orthopaedic

Sports Medicine

American Orthopaedic
Society for Sports Medicine

Product No. 02989
ISBN: 978-0-89203-575-5

Kibler

O
rthopaed

ic K
now

led
ge U

p
d
ate: Sports M

ed
icine 4

Sa
mp

le

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