The success of operative rotator cuff repair is variable, with rates of failure reported between 25% and 90%. Massive rotator cuff tears (an anteroposterior tear size > 5cm, coronal retraction to the glenoid rim, or ≥ 2 tendon involvement) have high rates of non-healing or re- rupturing and some even being irreparable. A deltoid strengthening program may be the most appropriate mode of treatment for these kinds of tears; particularly, in the elderly population. Deltoid re-education works by optimizing the function of the deltoid and remaining rotator cuff muscles.
In the uninjured shoulder, the deltoid and rotator cuff muscles work synergistically to maintain a balanced between transverse and coronal force couples that stabilizes the glenohumeral joint. 📌Indications and Contraindications In elderly patients who are unable or unwilling to undergo surgery, then deltoid re- education is the ideal option. Some would strongly argue that physiotherapy should be the first line of treatment for the massive rotator cuff tear. Also, patients who are relatively asymptomatic, who have acceptable pain levels (particularly absence of night pain) and a reasonable functional level may not see the benefit from surgical intervention, and instead may choose to be managed with non-surgical modalities. Deltoid retraining program is contraindicated in patients with antero-superior escape with glenohumeral arthritis and younger patients who request return of shoulder strength, particularly external rotation. Deltoid retraining program A full range of motion is desirable. This is achieved using passive self-assisted exercises (using the alternate limb, pulleys or walking stick) in the supine position initially, to eliminate any stiffness within the shoulder. The deltoid rehabilitation exercises are initially performed with the patient supine and the head supported. The patient is instructed to bring his arm to the upright position first and try to keep it upright with the contraction force of his deltoid muscle. Then, the aim is to actively move the arm with gravity eliminated within a comfortable forward active elevation arc. ➡️The next phase is for the patient to hold a small weight (e.g., a small bottle of water or tin of beans in their hand, again increasing the arc of motion as confidence increases. ➡️The final stage progresses to using the arm against gravity, initially in a semi-sitting and then in a standing position, first without the additional weight held in the hand and later with the weight. Assurance and education For patients to engage in the rehabilitation process it is important that they are educated about their condition. They should be reassured that pain in the shoulder does not correlate with harm, although conversely there is little to be gained by working the shoulder to the point of irritability. Realistic and achievable goals should be set as this maintains motivation and engagement in the programme. Posture Any postural issues of the shoulder girdle should be corrected from the outset, as this affects scapula positioning and physiotherapy sometimes needs to be directed here first. Activities to encourage proprioception by weight-bearing through the limb should also be included as there is usually a proprioceptive deficit in this situation. 🔖Takeaway message Chronic irreparable rotator cuff tears can cause substantial shoulder pain and disability. Many chronic irreparable rotator cuff tears can be treated non-operatively, especially when the shoulder has reasonably good function. Rehabilitation for rotator cuff tears is a valid and successful treatment modality. It should be particularly considered in those patients with chronic irreparable cuff tears, who are too frail or do not wish to consider surgery. The deltoid “re-education” program outlined in this chapter is a very useful tool.
2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain Recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017 Exercise therapy remains the intervention of choice for patellofemoral pain✔️ It is recommended that exercise targeting the hip and knee is a key component of management for all patients with patellofemoral pain, particularly when used in combination. Combined interventions and foot orthoses are recommended to reduce pain in the short to medium terms📣 The expert panel recommends the use of combined interventions (management programme incorporating exercise in conjunction with at least one of the following: foot orthoses, patellar taping or manual therapy) to reduce pain in the short and medium terms and prefabricated foot orthoses to reduce pain in the short term.
It should be noted that there is no evidence supporting combined interventions beyond 12 months for adults with patellofemoral pain. Prefabricated foot orthoses remain a recommendation for short-term relief of patellofemoral pain. 👟 Joint mobilisation and electrophysical agents are not recommended for patellofemoral pain♨️ The expert panel recommends against the use of patellofemoral, knee and lumbar mobilisation, as well as electrophysical agents, as primary interventions when managing patients with patellofemoral pain. It should be noted that patellofemoral mobilisation can be used as a component of a combined intervention approach where appropriate, with evidence and expert opinion in support. It is advised that these passive interventions should not be the focus of future RCTs.
An update of an evidence-based clinical guideline 📖 Predisposing factors 🔭 •When treating patients with an acute LAS, modifiable risk factors such as deficiencies in proprioception and ROM should be identified and if possible included in a prevention and/or rehabilitation program to mitigate the risk for recurrent sprains. •Extrinsic risk factors(type of sport practiced) although outside of the patient, may provide a significant increase in the risk at sustaining a LAS. *Prognostic factors Adequate attention should be directed towards the patient’s current level of pain, their workload and level of sports participation. These may all negatively influence recovery and increase the risk of future injury recurrence. * Diagnostics 🔬 Regarding the clinical assessment of damage to the anterior talofibular ligament, the sensitivity (8️⃣4️⃣%) and specificity (9️⃣6️⃣%) of assessment using the anterior drawer are optimised if clinical assessment is delayed for between 4️⃣ and 5️⃣ days post injury. In case of a suspected fracture, the OAR should be applied. * Treatment •Rest Ice Compression Elevation (RICE)♨️ There is no evidence that RICE alone, or cryotherapy, or compression therapy alone has any positive influence on pain, swelling or patient function. •Non-steroidal anti-inflammatory drugs💊 NSAIDs may be used by patients who have incurred an acute LAS for the primary purpose of reducing pain and swelling. However, care should be taken in NSAID usage as it is associated with complications and may suppress or delay the natural healing process. •Immobilisation🚷 Use of functional support and exercise therapy is preferred as it provides better outcomes compared with immobilisation. If immobilisation is applied to treat pain or oedema, it should be for a maximum of 10 days after which functional treatment should be commenced. *Functional treatment •Functional support Use of functional support for 4–6 weeks is preferred over immobilisation. The use of an ankle brace shows the greatest effects compared with other types of functional support. •Exercise Exercise therapy should be commenced after LAS to optimise recovery of joint functionality. Whether exercise therapy should be supervised or not remains unclear. •Manual mobilisation👋 A combination with other treatment modalities, such as exercise therapy, enhances the efficacy of manual joint mobilisation and is therefore advised. •Surgical therapy Despite good clinical outcomes of surgery after both chronic injuries and an acute complete lateral ligament rupture, functional treatment is still the preferred method as not all patients require surgical treatment. •Other therapies As no strong evidence exists on the effectiveness of these treatment modalities, they are not advised in the treatment of acute LAS * Prevention •Functional support💪 Both tape and brace have a role in the prevention of recurrent LAS (limited evidence). •Exercise therapy It is advised to start exercise therapy, especially in athletes, as soon as possible after the initial sprain to prevent recurrent LAS. Exercise therapy should be included into regular training activities as much as possible as home-based exercise.
No recommendations can be made concerning shoe wear. •Return to work To speed up return to work, a brace and immediate functional treatment in combination with a return to work schedule are advised. •Return to sports Supervised exercises focusing on a variety of exercises such as proprioception, strength, coordination and function will lead to a faster return to sport.