Fisioterapi pada Cedera Rotator Cuff Tears
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Konsep Dasar
❑ Rotator cuff tears and subacromial impingement are among the most common causes of shoulder pain and disability.
❑ The rotator cuff "complex" refers to the tendons of four muscles:
subscapularis, supraspinatus, infraspinatus, and teres minor.
❑ The rotator cuff has three well-recognized functions: rotation of the humeral head, stabilization of the humeral head in the glenoid socket by compressing the round head into the shallow socket, and the ability to provide "muscular balance," stabilizing the GH joint when other larger muscles crossing the shoulder contract.
Konsep Dasar
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❑ Rotator cuff tears can be classified as either acute or chronic, based on their timing, and as partial (articular or bursal side) or complete, based on the depth of the tear.
❑ Complete tears can be classified based on the size of the tear in square centimeters as described by Post (1983): small (0-1 cm2 ), medium (1-3 cm2), large (3-5 cm2), or massive (>5 cm2).
❑ multiple factors that significantly affect the postoperative rehabilitation program after repair of rotator cuff tears.
Konsep Dasar
❑ Type of Repair
Patients who have had deltoid muscle detachment or release from the acromion or clavicle (e.g., traditional open rotator cuff repair) may not perform active muscle contractions of the deltoid for 6 to 8 weeks. This is avoided to prevent avulsion of the deltoid.
Arthroscopic repair of the cuff actually has a slightly slower rate of rehabilitation progression owing to the weaker fixation of the repair compared with that of the open procedure. A mini-open procedure, involving a vertical split with the orientation of the deltoid fibers, allows mild, earlier deltoid muscular contractions
Konsep Dasar
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❑ Size of the Tear
Functional outcome and expectation after rotator cuff surgery are directly related to the size of the tear repaired.
❑ Tissue Quality
The quality of the tendon, muscular tissue, and bone helps determine speed of rehabilitation. Thin, fatty, or weak tissue is progressed slower than excellent tissue.
Konsep Dasar
❑ Location of the Tear
Tears that involve posterior cuff structures require a slower progression in external rotation strengthening. Rehabilitation after subscapularis repair (anterior structure) should limit resisted internal rotation for 4 to 6 weeks.
Restriction of the amount of passive external rotation motion should also be restricted until early tissue healing has occurred. Most tears occur and are confined to the supraspinatus tendon, the critical site of wear, often corresponding to the site of subacromial impingement.
Konsep Dasar
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❑ Onset of the Rotator Cuff Tear and the Timing of the Repair
Acute tears with early repair may have a slightly greater propensity to develop stiffness, and we are a little more aggressive in the ROM program.
Cofield (2001) noted that patients who underwent an early repair progressed more rapidly with rehabilitation than those with a laterepair.
Konsep Dasar
❑ Patient Variables
Several authors have reported a less successful outcome in older patients than young. This may be due to older patients’ typically having larger and more complex tears, probably affecting outcome.
❑ Rehabilitation Situation and Surgeon’s Philosophic Approach
Rehabilitation after rotator cuff surgery emphasizes immediate motion, early dynamic GH joint stability, and gradual restoration of rotator cuff strength. Throughout rehabilitation, overstressing of the healing tissue is to be avoided, striking a balance between regaining shoulder mobility and promoting soft tissue healing.
Proses Fisioterapi
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Proses Fisioterapi
❑ Robekan Akut
Patients with acute tears of the rotator cuff usually present to their physician after a traumatic injury. They have complaints of pain and sudden weakness, which may be manifested by an inability to elevate the arm.
On physical examination, they have a weakness in shoulder mobilization of forward elevation, external rotation, or internal rotation depending on which cuff muscles are involved.
Passive motion is usually intact depending on the timing of presentation. If the injury is chronic and the patient has been avoiding using the shoulder because of pain, there may be concomitant adhesive capsulitis (limitation of passive shoulder motion) and weakness of active ROM (underlying rotator cuff tear).
Proses Fisioterapi
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❑ Intervensi Robekan Akut
The recommended treatment for active patients with acute tears of the rotator cuff is surgical repair. Advantages of early operative repair include mobility of the rotator cuff, which allows technically easier repairs, good quality of the tendon, which allows a more stable repair, and in the patients with cuff tears associated with a dislocation, the repair will improve GH joint stability.
❑ Robekan Kronis
Chronic Tears Chronic rotator cuff tears may be an asymptomatic pathologic condition that has an association with the normal aging process. A variety of factors, including poor vascularity, a "hostile" environment between the coracoacromial arch and the proximal humerus, decreased use, or gradual deterioration in the tendon, contribute to the senescence of the rotator cuff, especially the supraspinatus.
Proses Fisioterapi
❑ Assessment Robekan Kronis
❑ On physical examination, some evidence of muscular atrophy may be seen in the supraspinatus fossa.
❑ Depending on the size of the tear, there may also be atrophy in the infraspinatus fossa.
❑ Passive motion is usually maintained, but may be associated with subacromial crepitus.
❑ Smooth active motion is diminished, and symptoms are reproduced when the arm is lowered from an overhead position.
❑ Muscle weakness is related to the size of the tear and the muscles involved.
❑ A subacromial injection of lidocaine may help to differentiate weakness that is caused by associated painful inflammation from that caused by a cuff tendon tear.
Proses Fisioterapi
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❑ Test Spesifik Assessment Robekan Kronis
❖ Internal rotation lag sign (subscapularis tear)
The patient sits or stands with the involved arm behind the back and the palm facing outward. The clinician grasps the patient’s shoulder with one hand and the wrist with the other and then lifts the patient’s arm off the back. The clinician then asks the patient to maintain this position as the wrist is released.
A positive test, which is manifested with an inability of the patient to maintain his or her arm off of the back, indicates a subscapularis tear.
Tautan Gambar Tautan Video
Proses Fisioterapi
❑ Test Spesifik Asessment Robekan Kronis
❖ External Rotation Lag Sign (Subscapularis Tear).
The patient sits with the clinician standing behind. The clinician grasps the patient’s wrist and then places the elbow at 90 degrees of flexion and the shoulder at 20 degrees of elevation in the scapular plane.
The clinician passively externally rotates the shoulder and, at the end range, asks the patient to maintain this position as the patient’s wrist is released. A positive test, which is indicated by lag that occurs with the inability of the patient to maintain his or her arm near full ER, indicates a supraspinatus/infraspinatus tear.
Tautan Gambar Tautan Video
Proses Fisioterapi
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❑ Test Spesifik Assessment Robekan Kronis
❖ Supraspinatus Test
The supraspinatus has traditionally been tested using the Jobe test or empty-can
position. The patient’s arm is positioned in IR within the scaption plane, at approximately 90 degrees of shoulder flexion. Manual resistance is then applied by the clinician in a direction toward the floor. The Jobe test can be performed similarly with the humerus externally rotated (full-can test).
A partial rupture of the supraspinatus tendon will result in abduction that is both weak and painful. A painless weakness with abduction could indicate a complete rupture of the supraspinatus tendon, although the deltoid cannot be ruled out.
Tautan Gambar
Tautan Video Full Can Test Tautan Video Empty can test
Proses Fisioterapi
❑ Test Spesifik Assessment Robekan Kronis
❖ Dropping Sign
Dropping Sign. The “dropping sign” is performed with the patient sitting or standing. The clinician places the patient’s elbow and shoulder at 90 degrees of flexion. The shoulder is then externally rotated to near end range and the patient is then asked to maintain this position as the wrist is released.
A positive test for an infraspinatus tear is indicated by a lag that occurs with an inability to maintain the position, and the arm drops to a neutral position of shoulder rotation. This is called the dropping sign.
Tautan Video
Protokol Rehabilitasi Cidera Rotator Cuff Tears
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Treatment of most patients with a chronic tear of the rotator cuff follows a conservative rehabilitation program. Operative intervention in this patient population is indicated for patients who are unresponsive to conservative management or demonstrate an acute tearing of a chronic injury.
The primary goal of surgical management of rotator cuff tears is to obtain pain relief. Additional goals, which are easier to achieve with acute rotator cuff tears than chronic rotator cuff tears, include improved ROM, improved strength, and return of function.
Tautan Protokol Rehabilitasi
Protokol Rehabilitasi Cedera Rotator Cuff Tears
❖ Surgical repair of a torn rotator cuff is done in an effort to decrease pain, increase function, and improve ROM.
❖ Postoperative care must strike a precarious balance between restrictions that allow for tissue healing, activities that return ROM, and gradual restoration of muscle function and strength.
❖ It is not uncommon to have residual postoperative stiffness and pain despite an excellent operative repair if the post op rehabilitation is not correct.
❖ Tautan protokol
Keterampilan Penerapan Intervensi (Demonstrasi)
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Konservatif
❖ Fase I
Passive ROM Exercise Capsular Stretching Hand Grip
❖ Fase II
Open chain w/ Theraband
Light isotonic dumble exercise Strengthening Deltoid
Latihan Fungsional 1:26, 1:51, 3:00
❖ Fase III
Plyometric I (Rotation Slams) 0:35 Plyometric w/ Explosion 3:22
Operatif
❖ Fase I
Passive ROM Exercise Hand Grip
❖ Fase II
Strengthening untuk stabilisasi
❖ Fase III
Open chain w/ Theraband
Light isotonic dumble exercise Strengthening Deltoid
Latihan Fungsional 1:26, 1:51, 3:00 Open Chain for scapular stabilization
Referensi
1. Buku Ortopedi
2. Buku babon rehabilitasi
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