Arthroscopic

Shoulder SLAP Repair Protocol ( Type II, IV & Complex Tears)

PHYSIOTHERAPY LED POST OPERATIVE SHOULDER CLINIC

COMPILED BY: TENDAYI MUTSOPOTSI BSc. HPT (Hons) MSc. ORTHO-MED MCSP MSOM
APPROVED BY: MR ANDREW SANKEY ORTHOPAEDIC CONSULTANT SURGEON

Arthroscopic Complex SLAP Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 Arthroscopic SLAP Repair Protocol (Type II, IV and Complex Tears) The purpose of this protocol is to provide the physiotherapist with a guideline for the post- operative rehabilitation course of a patient that has undergone an Arthroscopic Rotator cuff Repair. It is not intended to be a substitute for appropriate clinical decision-making regarding the progression of a patients post-operative course. The actual post surgical physiotherapy management must be based on the surgical approach, physical examination/findings, individual progress, and/or the presence of post-operative complications. In case of a patient with a concomitant injury/repair (such as a rotator cuff repair) the treatment will vary- consult he Surgeon. If a physiotherapist requires assistance in the progression of a post-operative patient they should consult with Mr. Andrew Sankey (Shoulder Consultant) or Mr. Tendayi Mutsopotsi (Specialist Shoulder Therapist) Please Note: The protocol is divided into phases. Each phase is adaptable based on the individual and special circumstances. Immediately post-operatively, exercises must be modified so as not to place unnecessary stress to SLAP repair. Early passive range of motion is highly beneficial to enhance circulation within the joint to promote healing. The overall goals of the surgical procedure and rehabilitation are to: Control pain and inflammation Regain normal upper extremity strength and endurance Regain normal shoulder range of motion Achieve the level of function based on the orthopedic and patient goals The physical therapy should be initiated within the first week and one half to two weeks post-op. The supervised rehabilitation program is to be supplemented by a home exercise program where the patient performs the given exercises at home or at a gym facility. Important post-operative signs to monitor include: Swelling of the shoulder and surrounding soft tissue Abnormal pain response, hypersensitive-an increase in night pain Severe range of motion limitations Weakness in the upper extremity musculature Return to activity requires both time and clinical evaluation. To most safely and efficiently return to normal or high level of functional activity, the patient requires adequate strength, flexibility, and endurance. Functional evaluation including strength and range of motion testing is one method of evaluating a patients readiness to return to activity. Return to intense activities following an arthroscopic rotator repair requires both a graded strengthening and range of motion program along with a period of time to allow for tissue healing. Symptoms such as pain, swelling, or the patient should closely monitor instability. Progression to the next phase based on Clinical Criteria and/or Time Frames as appropriate. Type I SLAP lesions consist of degenerative fraying of the superior labrum but the biceps attachment to the labrum is intact. The biceps anchor is intact. Type II SLAP lesions are created when the biceps anchor has pulled away from the glenoid attachment. Type III SLAP lesions involve a bucket-handle tear of this superior labrum with an intact biceps anchor.
Arthroscopic Complex SLAP Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Type IV SLAP lesions involve a bucket-handle tear of the superior labrum in which the tear extends into the biceps tendon. The torn biceps tendon and labrum are displaced into the joint. Complex SLAP lesions involve a combination of two or more SLAP types, usually II and III or II and IV. Repair of Type II SLAP Lesion1: Generally the superior labrum should be reattached to the glenoid and the biceps anchor stabilized. Overhead-throwing athletes with this lesion often present with the biceps tendon detached from the glenoid rim. Peel-back lesions are also commonly seen. When developing rehabilitation programs it is important to determine the extent of the lesion, as well as the location and number of sutures.

Repair of Type IV SLAP Lesion1: Similar to Type II repair; however, will involve biceps repair, resection of frayed area or tenodesis. Rehabilitation is similar to that for Type II repair except for biceps activity. Timeframes for active and resisted biceps activity will vary depending on the extent of bicipital involvement. Consultation with the surgeon regarding the progression of biceps activity based on the integrity of the biceps tendon repair is required. In cases where the biceps is resected, biceps muscular contractions typically may begin between six and eight weeks post surgery In cases of repair to biceps tears or biceps tenodesis, no resisted biceps activities is typically advised for three months following surgery. Light isotonic strengthening for elbow flexion is initiated between weeks 12 and 16 postoperatively (in cases with a biceps tenodesis surgeon and therapist may choose to wait until 16 weeks to begin. Full resisted biceps activity is not initiated until post op weeks 16 to 20. Progression to sport-specific activities, such as plyometrics and interval sport programs, follows similar guidelines to those outlined for Type II SLAP repairs

Phase I: Immediate Post Surgical Protected Phase (Day 1-week 3) Goals: Protect the anatomic repair Prevent/minimize the side effects of immobilization Promote dynamic stability Diminish pain and inflammation Post Operative (day 1 -Week 2) Sling for 4 weeks and sleep in sling for 4 weeks Wrist AROM /AAROM) and Hand-gripping exercises PROM/AAROM: -Flexion and elevation in the plane of the scapula to 60 (week 2, flexion to 75) -External rotation (ER)/internal rotation (IR) with arm in scapular plane (-ER to 15 and -IR to 45)

Arthroscopic Complex SLAP Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

No AROM ER, extension, or abduction Submaximal isometrics for all rotator cuff, periscapular, and shoulder musculature No isolated biceps contractions (i.e. e. no active elbow flexion) Cryotherapy modalities as indicated

Weeks 3-4 Discontinue use of sling at 4 weeks Continue gentle PROM/AAROM exercises (Rate of progression based on patients tolerance) O Flexion and elevation in the plane of the scapula to 90 o Abduction to 85, ER in scapular plane to 30, IR in scapular plane to 60 No AROM ER, extension, or elevation Initiate rhythmic stabilization drills within above ROM Initiate proprioceptive training within above ROM Progress isometrics as above Continue use of cryotherapy, modalities as indicated

Weeks 5-6 Begin AROM of shoulder (all planes, gravity eliminated positions then gravity resisted position once adequate mechanics): Gradually improve PROM and AROM o Flexion and elevation in the plane of the scapula to 145 o Abduction to 145, External rotation to 50, Internal rotation 60, Extension to tolerance May initiate gentle stretching exercises Gentle Proprioceptive Neuromuscular Facilitation (PNF) manual resistance Scapula exercise progression Begin AROM elbow flexion and extension NO biceps strengthening

Phase II: Intermediate Phase-Moderate Protection Phase (Weeks 6-12) Weeks 7-9 Gradually progress P/AROM o Flexion, elevation in the plane of the scapula, and abduction to 180 o External rotation to 95 and Internal rotation to 75 at 90 abduction o Extension to tolerance Begin isotonic rotator cuff, periscapular and shoulder strengthening program Throwers Ten Programme Type II repairs: begin sub maximal pain free biceps isometrics Type IV and complex repairs: continue AROM elbow flexion and extension, no biceps Isometric or isotonic strengthening

Arthroscopic Complex SLAP Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Weeks 10-12 Progress ER P/AROM to thrower's motion o ER 110-115 at 90 abduction in throwers (weeks 10-12) Progress shoulder isotonic strengthening exercises as above Continue all stretching exercises as need to maintain ROM. Progress ROM to functional demands (i.e., overhead athlete) Type II repairs: begin gentle resisted biceps isotonic strengthening @ week 12 Type IV, and complex repairs: begin gentle sub maximal pain free biceps isometrics

Criteria for Progression to Phase IV Full non painful ROM Good stability Muscular strength 4/5 or better No pain or tenderness Phase IV: Minimal Protection Phase (weeks 14-20) Goals Establish and maintain full ROM Improve muscular strength, power, and endurance Gradually initiate functional exercises Weeks 14-16 Continue all stretching exercises (capsular stretches) Maintain thrower's motion (especially ER) Continue rotator cuff, periscapular, and shoulder strengthening exercises Type II repairs: progress isotonic biceps strengthening as appropriate Type IV, and complex repairs: progress to isotonic biceps strengthening as appropriate "Thrower's Ten" program with biceps exercise or fundamental exercises PNF manual resistance and Endurance training Initiate light plyometric program Restricted sports activities (light swimming, half golf swings)

Weeks 16-20 Continue all exercises listed above Continue all stretching Continue "Thrower's Ten" program Continue polymeric program Initiate interval sport program (e.g. throwing).

Criteria for Progression advanced strengthening Full non painful ROM Satisfactory static stability Muscular strength 75-80% of contralateral side No pain or tenderness

Arthroscopic Complex SLAP Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Weeks 20-26: Advanced Strengthening Phase Goals Enhanced muscular strength, power, and endurance Progress functional activities Maintained shoulder stability Weeks 20-26 Continue flexibility exercises Continue isotonic strengthening program PNF manual resistance patterns Plyometric strengthening Progress interval sports programs

Months 6-9: Return to Activity Phase Goals Gradually progress sport activities to unrestrictive participation Continue stretching and strengthening program Returning to functional activities

Returning to work Driving Swimming Golf Lifting Contact Sport Sedentary job: as tolerated Manual job: 6 weeks-3 months depending on Consultants opinion About 3-6 weeks Breaststroke: 3 weeks Freestyle: 6 weeks At least 6 weeks Light lifting can be started at 3 weeks. Avoid lifting heavy objects for 3 months. Such as rugby, football, racket sports, rock climbing etc: 6 weeks-3 months depending on Consultants opinion

Milestone driven These are milestone driven guidelines designed to provide an equitable rehabilitation service to all of our patients. They will also limit unnecessary visits to the outpatient clinic here at Chelsea & Westminster by helping the patient and therapist to identify when specialist review is required. If patients are progressing satisfactorily and meeting milestones, there is no need for them to attend clinic routinely.
Arthroscopic Complex SLAP Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Failure to progress or variations from the norm should be the main reason for clinic attendance. Both patients and therapists can book clinic visits by contacting the numbers given further on in this document. Milestones for discharge: 1. Achieved time and patient specific functional goals. 2. Achieved 90-100% of contralateral shoulder active ROM. 3. Patient has a negative lag sign (i.e. active equals passive range) with dynamic rotation control at 0 abd, 45 abd, 90 abd. 4. Patient has no apprehension with specific movements and activities. Failure to meet milestones: 1. Refer to/discuss with Shoulder and Elbow Unit 2. Consider possible reasons for failure to progress and act accordingly (see below). 3. Continue with outpatient physiotherapy while patient is still making progress. Clinic follow-up schedule: at 2, 6, 12, and 16-24 months (only if necessary)
Arthroscopic Complex SLAP Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

 Failure to progress If a patient is failing to progress, then consider the following: Possible problem Pain inhibition Action Adequate analgesia Keep exercises pain-free Return to passive ROM if necessary until pain controlled Progressing too quickly hold back If severe night pain/resting pain refer to Shoulder Unit Patient exercising too vigorously Increase or reduce physiotherapy/ Patient not doing home exercise (HEP) (max 2-4x/day) for few programme (HEP) regularly enough days/weeks and assess difference Ensure HEP focuses on key exercises and link to function Returned to activities too soon Decrease activity intensity Cervical/thoracic pain referral Assess and treat accordingly Unable to gain strength Passive ROM may need improving Altered neuropathodynamics Assess and treat accordingly Poor rotator cuff control Ensure passive range gained first Consider isometrics through range Rotation dissociation through range with decreasing support and increasing resistance Ensure not progressing through Therabands too quickly Poor scapula control Work on scapula stability through Range without fixing with pec major/lat dorsi Poor core stability Work on improving core stability Secondary frozen shoulder Maintain passive ROM as able Use physiological and accessory mobilisations, taking into account end feel and tissue healing times It is essential you contact us if you have any concerns. THE SHOULDER UNIT TEAM Shoulder Consultant: Mr. Andrew Sankey 0203 315 8545 Shoulder Therapist: Mr. Tendayi Mutsopotsi 0208 746 8404 Secretary: Mr. 0208 746 8545 :

Arthroscopic Complex SLAP Repair Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)