Page 25 - ISAKOS 2019 Newsletter Volume 1

Rehabilitation After Arthroscopic Shoulder Surgery
Alfonso R. Barnechea, MD
Hospital Nacional Edgardo Rebagliati Martins – EsSalud Lima, PERU
As surgeons, our main objective after treating musculoskeletal injuries and conditions is to restore functionality and well-being to the patients under our care. To do so, we must focus first on the mechanical repair or reconstruction of injuries that otherwise would not heal appropriately (or at all). We also understand that, in patients with shoulder injuries, the specific organ or structure involved is not the only one that is affected; because shoulder function is dependent on soft-tissue balancing and neuromuscular coordination, shoulder injuries tend to compromise many adjacent (or even distant) musculoskeletal structures throughout the kinetic chain.
The shoulder is held in place by both static structures (e.g., the capsulolabral complex, glenohumeral ligaments, etc.) and dynamic structures (e.g., the rotator cuff and extrinsic muscles, scapular dynamic stabilizers, etc.). Also, the coordination and balance of the scapular muscles is fundamental to ensure stability of the scapula, which translates into a secure, stable platform on which all glenohumeral motion occurs.
Following an injury that comprises one or more structures within the shoulder, unconscious and conscious compensation occurs. Specifically, muscles that are used primarily for scapular stabilization start to produce motion, resulting in a loss of neuromuscular balance and, in turn, greater energy consumption, fatigue, and contracture of many peripheral stabilizers. In addition, the lack of glenohumeral motion due to pain or weakness starts a process of capsular shrinking and thickening, muscular atrophy, and chronic pain.
Challenges Related to Rehabilitation Therapy
Deciding Whether and When to Prescribe Physical Therapy
After performing an arthroscopic procedure, the surgeon must make several decisions regarding postoperative management. First, the surgeon must decide whether to send the patient to therapy; some surgeons still do not prescribe a formal therapy program for their patients.
Second, the surgeon must decide when to send the patient for therapy. Unfortunately, there is no consensus about when to start therapy, given the heterogeneity and low quality of evidence on the subject. Usually, this decision is made after considering the time that it will likely take for the repaired tissue to heal as well the magnitude of both the injury and the repair.
Designing and Implementing the Rehabilitation Plan
Once the decision has been made to send the patient to therapy, the surgeon must consider many factors regarding the rehabilitation system. One such factor is the number of steps that the patient must go through before finally reaching the therapist. In some systems, the surgeon sends the patient directly to the therapist, who evaluates the patient, designs a therapy plan, discusses the plan with the surgeon and, finally, applies the plan in conjunction with the patient. In other systems, a physiatrist interprets the surgeon’s request and then designs a therapy plan, which is then executed by the therapist. In most cases involving the latter type of system, the patient receives therapy from different therapists, each with different ideas and manners of applying the techniques indicated by the physician, which can lead to either insufficient or overaggressive maneuvers and, ultimately, to undesirable results.
Type and Duration of Immobilization
The type and duration of immobilization after a repair also vary widely between surgeons; however, a 4 to 6-week immobilization period is generally preferred because of the time needed for tendons and/or capsulolabral structures to heal. With regard to the position of the limb when in a sling, there is no consensus about whether to leave the sling in rest position or to use abduction/rotation pillows.
General Principles of Shoulder Rehabilitation After Arthroscopic Surgery (Box 1)
Box 1
General Principles of Rehabilitation Following Shoulder Surgery
• Incorporate scapular stabilization exercises • Protect the repair(s)
• Avoid or minimize stiffness
• Recover upper-limb kinetic chain
Three Stages of Recovery
Following a shoulder repair, there are three recognizable phases to recovery. The first phase, which usually lasts for 6 to 8 weeks, is characterized by healing of the repaired or grafted tissue into its osseous or soft-tissue attachment (e.g., cuff-to-footprint healing or labrum-to-glenoid healing).
CURRENT CONCEPTS
ISAKOS NEWSLETTER 2019: VOLUME I 23