The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation for anatomic total shoulder arthroplasty.

Anatomic total shoulder arthroplasty is the gold standard shoulder replacement procedure for patients with an intact rotator cuff and sufficient glenoid bone to accommodate prosthetic glenoid implant and offers reliable patient satisfaction, excellent implant longevity, and a low incidence of complications. Disparity exists in the literature regarding rehabilitation strategies following anatomic total shoulder arthroplasty. This article presents a consensus statement from experts in the field on rehabilitation following anatomic total shoulder arthroplasty. The goal of this consensus statement is to provide a current evidence-based foundation to inform the rehabilitation process after anatomic total shoulder arthroplasty. These guidelines apply to anatomic total shoulder arthroplasty (replacement of the humeral head and glenoid), hemiarthroplasty (replacing only the humeral head), and hemiarthroplasty with glenoid reaming or resurfacing. The consensus statement integrates an extensive literature review, as well as survey results of the practice patterns of members of the American Society of Shoulder and Elbow Therapists and the American Shoulder and Elbow Surgeons. Three stages of recovery are proposed, which initially protect and then gradually load soft tissue affected by the surgical procedure, such as the subscapularis, for optimal patient outcomes. The proposed guidelines should be used in collaboration with surgeon preferences and patient-specific factors.

The position of sling immobilization influences the outcomes of anatomic total shoulder arthroplasty: a randomized, single-blind, prospective study.

BACKGROUND: To date, no studies have been published that have assessed the optimal position of sling immobilization after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis. METHODS: Thirty-six patients undergoing anatomic total shoulder arthroplasty for osteoarthritis were randomized to a neutral rotation sling versus an internal rotation sling. The primary outcomes assessed included the Disabilities of the Arm, Shoulder and Hand score; Western Ontario Osteoarthritis of the Shoulder score; Single Assessment Numeric Evaluation score; visual analog scale (VAS) scores for pain and satisfaction; compliance ratings; and radiographic and range-of-motion measurements. Primary outcomes were assessed at baseline and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. RESULTS: All patient-determined outcome scores for both groups revealed statistically significant improvements (P < .0001) from enrollment to final follow-up. There were statistically significant advantages to the neutral rotation sling group compared with the internal rotation sling group when we evaluated the improvements in (1) active external rotation (42° vs 25°, P = .03), (2) passive external rotation (44° vs 26°, P = .02), (3) passive horizontal adduction (7.7 cm vs 3.7 cm, P = .05), and (4) pain relief with passive adduction (VAS score, 6.2 cm vs 3.5 cm; P = .002). There was a trend toward greater improvements in the neutral rotation sling group when we measured (1) active horizontal adduction (8.3 cm vs 2.9 cm, P = .06) and (2) active internal rotation behind the back (18 cm vs 11.1 cm, P = .09). At 2 weeks, the neutral rotation sling group had significantly less night pain than the internal rotation sling group (mean VAS score, 18 mm vs 34 mm; P = .047). CONCLUSIONS: Neutral rotation sling use after anatomic total shoulder arthroplasty resulted in statistically significant improvements in external rotation and adduction, as well as decreased night pain, compared with an internal rotation sling.

SCAPULAR SUBSTITUTION AFTER ROTATOR CUFF REPAIR CORRELATES WITH POSTOPERATIVE PATIENT OUTCOME.

BACKGROUND: Scapular substitution is an alteration of scapulohumeral kinematics that may occur when patients have shoulder pain or dysfunction. These abnormal scapular kinematic patterns have been recognized in patients with rotator cuff tears. It remains unknown if 1) normal scapular kinematics can be restored with rehabilitation after rotator cuff repair surgery and 2) abnormal scapular kinematics are associated with inferior patient-determined outcome scores, range of motion, or strength. PURPOSE: The purpose of this study was to determine 1) if scapular substitution can be decreased or improved with rehabilitation after rotator cuff repair surgery and 2) if the presence or amount of scapular substitution was correlated with patient-determined outcome scores, range of motion, or strength after rotator cuff repair surgery. STUDY DESIGN: Retrospective review of prospectively collected data (LOE IV). METHODS: Forty-eight patients who underwent post-operative rehabilitation after an arthroscopic rotator cuff repair were reviewed for this study. The outcomes measures of interest included: patient-determined outcome scores (WORC, Simple Shoulder Test, the ASES Score, the Shoulder Activity Score, and the SANE rating), identification and quantification of scapular substitution, active range of motion, and strength. Outcomes were prospectively collected up to 12 months after surgery and assessed retrospectively. RESULTS: As patients progress through their first year of rehabilitation from a rotator cuff repair, the amount of scapular substitution decreases but remains statistically significantly greater than the contralateral, asymptomatic side. At all post-operative time points, patients with scapular substitution, (determined subjectively by a physical therapist), had 1) inferior WORC, ASES, SANE, and SST scores, 2) inferior flexion, abduction, and external rotation range of motion, and 3) inferior scaption strength compared to those patients without subjective scapular substitution. CONCLUSIONS: Rehabilitation decreases but does not normalize the amount of scapular substitution up to one year after rotator cuff repair. Subjective identification of scapular substitution is associated with inferior patient-determined outcome scores, range of motion, and strength. LEVEL OF EVIDENCE: 4 - Prognosis study.

The influence of anatomic total shoulder arthroplasty using a subscapularis tenotomy on shoulder strength.

BACKGROUND AND HYPOTHESIS: There is limited evidence describing the influence of total shoulder arthroplasty on strength. The hypothesis was that after total shoulder arthroplasty, strength would improve compared with the preoperative state but remain inferior to that of the nonoperative shoulder. An additional aim was to determine whether strength improvement was associated with improvements in outcome scores and motion. MATERIALS AND METHODS: Thirty-six patients underwent total shoulder arthroplasty, with 31 patients (86%) having 1 year of follow-up for all outcomes. Patient-determined outcomes (Western Ontario Osteoarthritis of the Shoulder score; Disabilities of the Arm, Shoulder and Hand score; Single Assessment Numeric Evaluation rating; and shoulder activity level), range of motion, and strength were assessed. Isometric strength was determined for scaption and external rotation, as well as the liftoff test, belly-press test, and bear-hug test. RESULTS: All strength measures improved, with significant increases in external rotation, the liftoff test, and the bear-hug test, but remained inferior to the nonoperative-side strength. Improved strength in the belly-press test was associated with greater improvement in Single Assessment Numeric Evaluation scores. Improvements in scaption and belly-press testing were associated with improvements in active flexion. Strength improvements in the liftoff test were associated with improved internal rotation in 90° of abduction. Patients with improvements in strength had improvements in their shoulder activity level from baseline to final follow-up, whereas patients without improved strength test findings did not have improved shoulder activity levels. CONCLUSIONS: Total shoulder arthroplasty improved external rotation, liftoff, and bear-hug strength testing. Operative shoulder strength remained inferior to strength of the nonoperative shoulder. Patients with improvements in strength were more likely to have greater improvements in outcome scores and range of motion. Improvements in the shoulder activity level after anatomic total shoulder arthroplasty may be dependent on improvements in strength.

Are Pulley Exercises Initiated 6 Weeks After Rotator Cuff Repair a Safe and Effective Rehabilitative Treatment? A Randomized Controlled Trial.

BACKGROUND: There are few level 1 or 2 evidence studies that examine rehabilitation after rotator cuff repair. Pulleys have been used in postoperative shoulder rehabilitation with the intention of improving range of motion and developing strength. There is a concern that the use of pulleys in rehabilitation of rotator cuff repairs may contribute to excessive scapular motion (scapular substitution) and potentially inferior outcomes. HYPOTHESIS: Rotator cuff repair patients treated with pulley exercises would have increased scapular substitution and inferior patient-determined outcome scores, range of motion, and strength compared with patients treated with an alternative rehabilitation program without pulleys. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 27 patients who underwent rotator cuff repair were randomized to a rehabilitation group that used pulleys initiated 6 weeks postoperatively, and 26 patients followed a rehabilitation protocol without pulleys. Inclusion criteria were patients undergoing arthroscopic rotator cuff repair. Exclusion criteria were large to massive rotator cuff tears, revision rotator cuff repair, glenohumeral osteoarthritis, adhesive capsulitis, and a symptomatic contralateral shoulder. Outcomes of intervention were patient-determined outcome scores (Western Ontario Rotator Cuff Index [WORC], American Shoulder and Elbow Surgeons [ASES] Shoulder Score, Single Assessment Numeric Evaluation [SANE], Shoulder Activity Level, and Simple Shoulder Test [SST]), range of motion, scapular substitution, and strength. Outcomes were determined at 6, 12, 18, 26, and 52 weeks. A power analysis determined that 22 patients were needed per group to have a power of 0.80, α = 0.05, and effect size of f = 0.5. RESULTS: Both groups had statistically significant improvements in WORC, ASES Shoulder Score, SST, and SANE scores over time after rotator cuff repair (P < .0001). There were no differences between the interventions for WORC (P = .18), ASES Shoulder Score (P = .73), SANE (P = .5), Shoulder Activity Level (P = .39), or SST (P = .36). Both interventions demonstrated improvements in shoulder flexion (P = .002), abduction (P = .0001), external rotation (P = .02), strength (P ≤ .0002), and scapular substitution (P ≤ .07) over time after rotator cuff repair. However, there was no difference in range of motion (P ≥ .26), strength (P ≥ .20), or scapular substitution (P ≥ .17) between interventions. CONCLUSION: A rotator cuff repair rehabilitation program that uses pulleys does not result in inferior outcomes, as determined by patient-determined outcome scores, measurements of scapular substitution, range of motion, and scaption strength. REGISTRATION: ClinicalTrials.gov NCT01819909.