Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete

Current Evidence Based Recommendations on Rehabilitation following Arthroscopic Shoulder Surgery: Rotator Cuff, Instability, Superior Labral Pathology, and Adhesive Capsulitis

PURPOSE OF REVIEW

Arthroscopy has become increasingly popular for a addressing a wide variety of shoulder pathology. However, despite increasing interest, there is still much uncertainty and variability amongst providers regarding optimal post-operative rehabilitation. This review provides an overview of the evidence underlying common rehab protocols used following arthroscopic interventions for rotator cuff disease, shoulder instability, superior labral anterior to posterior (SLAP) tears and adhesive capsulitis.

RECENT FINDINGS

For small and medium sized rotator cuff tears, early motion protocols do not seem to affect healing or retear rates, however there is no difference with regards to long term functional outcomes when compared to standard motion protocols. For larger tears (> 3 cm), early active motion may be associated with impaired tendon integrity. Early range of motion following arthroscopic Bankart repair has not been shown to increase rate of recurrence, however the data on return to sport requires more granularity to effectively guide care. Further research needs to be done to compare rehab protocols following SLAP repair and arthroscopic capsular release. Rehabilitation protocols following rotator cuff surgery and anterior shoulder stabilization have garnered the most research interest. However, there is still a need for larger higher-level studies examining the long-term effects of different rehab protocols. Regarding the arthroscopic management of other types of shoulder instability, SLAP tears and adhesive capsulitis, there is paucity of high-quality evidence. This knowledge gap likely underpins the variability in different rehab protocols seen in clinical practice, highlighting the need for more research.

Regaining motion among patients with shoulder pathology - are all exercises equal?

Background

Little information exists to guide the choice of exercise for regaining shoulder range of motion (ROM). The purpose of this study was to compare the maximal ROM reached, pain and difficulty associated with 4 commonly prescribed exercises.

Methods

Forty (9 females) patients with various shoulder disorders and a limited flexion ROM performed 4 exercises for regaining shoulder flexion ROM in a randomized order. Exercises included the self-assisted flexion, forward bow, table slide and rope-and-pulley. Participants were videotaped while performing all exercises and the maximal flexion angle reached during each exercise was recorded using Kinovea motion analysis freeware (Kinovea 0.8.15). Pain intensity and the perceived level of difficulty associated with each exercise were also recorded.

Results

The forward bow and table slide generated significantly greater ROM compared with the self-assisted flexion and rope-and-pulley (P ≤ 0.005). The self-assisted flexion was associated with a greater pain intensity compared with the table slide and rope-and-pulley (P = 0.002) and a greater perceived level of difficulty compared with the table slide (P = 0.006).

Conclusions

Due to the greater ROM allowed, and similar or even lower level of pain or difficulty, clinicians may wish to initially recommend the forward bow and table slide for regaining shoulder flexion ROM.

Single-Portal Arthroscopic Posterior Shoulder Stabilization

Posterior shoulder instability occurs when the labrum detaches posteriorly from the glenoid owing to significant trauma and is a relatively uncommon type of shoulder dislocation. Although posterior instability has often been treated with open shoulder stabilization, modern arthroscopic procedures are being rapidly pursued by surgeons as an improved option because of decreased invasiveness and reduced operative times. Arthroscopic stabilization of the posterior glenoid labrum typically involves 2 working portals, but the procedure still yields successful results when performed with a single posterior portal and a suture passer. Our technique involves 1 less portal to reduce invasiveness, lower the risk of nerve damage, and decrease the operative time and postoperative pain. The purpose of this article is to describe an arthroscopic posterior stabilization technique with a single working portal.

Variability in Rehabilitation Protocols after Superior Labrum Anterior Posterior Surgical Repair

Introduction

Rehabilitation after a superior labral anterior posterior (SLAP) repair is an important aspect of patient outcomes; however, no standardized rehabilitation protocol has been defined. The purpose of this paper is to assess the variability of rehabilitation after a SLAP repair to understand the need for standardization to improve patient outcomes.

Methods

Protocols for SLAP repairs were collected through a search for Academic Orthopedic Programs and a general Google search using the terms “[Program Name (if applicable)] SLAP Repair Rehab Protocol”. Protocols were compared by sling, range of motion (ROM), physical therapy, return to sport (RTS), return to throwing, and biceps engagement and tenodesis recommendations. Protocols for non-operative or generalized shoulders were excluded.

Results

Sixty protocols were included. A total of 61.7% (37/60) recommended a sling for four to six weeks and 90% (54/60) included a full ROM recommendation, but time was variable. There were different exercises recommended, but pendulum swings were recommended by 53% (32/60), submaximal isometrics by 55% (33/60), and scapular strengthening by 65% (39/60). Of the sixty protocols, 33% (20/60) recommended return to sports in 24 weeks and 38.3% (23/60) recommended allowing throwing in 16 weeks.

Conclusions

There was variability in protocols for SLAP repair, especially time until full ROM, RTS, and biceps strengthening. Time in sling and scapular strengthening were the least variable. A lack of specificity within protocols in what return to throwing meant for functional ability made it difficult to compare protocols. Considering the large number of orthopedic programs, a relatively small number had published protocols. Further studies are needed to evaluate a standardized post-operative rehabilitation for SLAP repairs to improve outcomes.

Return to Play and Performance Perceptions of Baseball Players After Isolated SLAP Tear Repair

Background:

Variable return-to-play (RTP) rates have been reported after surgical repair of superior labral anterior-posterior (SLAP) tears in baseball players. Many studies, however, have not controlled for concomitant shoulder injuries.

Purpose/Hypothesis:

The purpose of this study was to evaluate rates of RTP and return to previous or higher performance level (RTPP) and long-term outcomes after isolated SLAP tear repair. The hypothesis was that improved outcomes would be identified compared with previous reports.

Study Design:

Case series; Level of evidence, 4.

Methods:

The records of 232 players who underwent isolated SLAP tear repair from 2004 to 2014 were reviewed. A total of 98 players who were at least 12 months out from surgery were identified. Through telephone interviews, participants completed the Western Ontario Shoulder Instability Index (WOSI) and Veterans RAND 12-Item Health Survey (VR-12) and answered scripted questions about RTP, RTPP, and current symptoms.

Results:

Of the 98 players who met the inclusion criteria, 73 (74.5%) participated. The mean age at the time of surgery was 19.8 ± 2.9 years. The mean follow-up time was 86.2 ± 25.1 months overall; it was 84.4 ± 24.4 months for pitchers and 90.3 ± 26.7 months for other position players, (P = .40). There were 10 professional, 36 collegiate, and 27 high school players. Most players perceived successful RTP (83.6%), including 80.0% of pitchers and 91.3% of other position players (P = .23). However, RTPP rates were lower, at 52.3% (n = 26) and 78.3% (n = 18) for pitchers and other position players, respectively (P = .03). Pitchers were younger at the time of surgery (19.3 ± 3.0 vs 20.8 ± 3.0 years, respectively; P = .03) and had greater perceived shoulder and general health impairments compared with other position players (P ≤ .02). Players who perceived successful RTPP had better WOSI of the healthy shoulder and individual physical, sports, lifestyle, and emotion scores compared with players who did not perceive successful RTPP.

Conclusion:

After the surgical repair of isolated type II or greater SLAP tears, other position players displayed superior RTP (91.3% vs 80.0%, respectively) and RTPP (78.3% vs 52.3%, respectively) rates than pitchers. Long-term follow-up suggests that pitchers may perceive greater long-term impairments than other position players and are less likely to return to their previous or higher performance level.

Surgical Management of the Aging Athlete

Epidemiologic data show that the number of middle aged (>40 yr) and elderly (>65 yr) individuals continues to increase steadily, creating an expanding need for sports medicine care. Management of injuries in this subset of patients is expanding well beyond sustaining a patient's ability to perform activities of daily living. In fact, many older individuals increasingly expect to maintain reasonably high activity levels throughout their lifespan as well as after musculoskeletal injury. While a number of the emerging physiologic benefits of physical activity in older patients have been outlined, no recent review has outlined the current best surgical techniques, rehabilitation protocols, and return-to-sport recommendations for older athletes after soft-tissue repair or reconstruction as well as joint replacement. The goal of orthopaedic care in the elderly patient is shifting from simple pain relief toward return to athletic activity.

Biceps Disorder Rehabilitation for the Athlete: A Continuum of Moderate- to High-Load Exercises

BACKGROUND

Progressive biceps loading is recommended in the nonoperative and operative rehabilitation of biceps-related disorders. Previous researchers have proposed a continuum of exercises with low to moderate biceps loads to be used in the early and intermediate phases of rehabilitation. A progression of exercises with moderate to high biceps loads to be used in the more advanced phases of rehabilitation is lacking.

PURPOSE

To describe a progression of exercises with progressive moderate to high loads on the biceps brachii (BB) based on electromyographic (EMG) analysis.

STUDY DESIGN

Controlled laboratory study.

METHODS

The EMG activity of BB and triceps brachii; upper trapezius, middle trapezius, and lower trapezius; and serratus anterior was determined with surface electromyography in 30 asymptomatic participants during 11 exercises.

RESULTS

Of the 11 exercises, 4 (arm shake with an Xco-trainer, lateral pull-down in pronation, chest shake with an Xco-trainer, lateral pull-down in supination) showed low (<20% maximal voluntary isometric contraction [MVIC]), 5 (pull-up in pronation with Redcord, air punch, forward flexion in supination, pull-up in supination with Redcord, inclined biceps curl) showed moderate (between 20%-50% MVIC), and 2 (throwing forward flexion, reverse punch) showed high (>50% MVIC) EMG activity in the BB. These exercises were ranked with an increasing level of activity in the BB.

CONCLUSION

The continuum of exercises with moderate to high biceps activity may be applied in the more advanced phases of treatment for biceps disorders. In addition, biceps muscle activity may be targeted by (1) sagittal plane elevation; (2) elbow flexion with supination, without upper arm support; (3) biceps contraction from an elongated position; or (4) high-velocity, explosive exercises.

CLINICAL RELEVANCE

These findings may assist clinicians to select appropriate exercises to be used in the more advanced phases of nonoperative or postoperative rehabilitation of overhead athletes with biceps-related injuries.

[Rehabilitation concepts and return to sport after interventions on the shoulder]

BACKGROUND

Rehabilitation of athletes following surgical interventions for shoulder injuries is of utmost importance for recovery and return to sport.

OBJECTIVES

The aim was to determine adequate concepts for rehabilitation following shoulder surgery in athletes.

METHODS

A selective literature search was carried out in PubMed and a review of the available concepts is given taking personal experiences as well as national and international recommendations into consideration.

RESULTS

This article presents the basic principles of functional rehabilitation, the kinetic chain and the different phases in rehabilitation. Specific rehabilitation concepts and return to sport strategies following traumatic dislocation, superior labrum anterior to posterior (SLAP) lesions and rotator cuff tears are presented. There is little high-level scientific evidence available for the treatment of these patients and most concepts are based on clinical experience and expert opinion.

CONCLUSION

Rehabilitation of athletes with shoulder injuries requires a broad consensus strategy with respect to the next steps. Individual concepts for rehabilitation should take surgical and patient-specific criteria into consideration. Further research is urgently required to develop evidence-based recommendations.

Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps

BACKGROUND

Although rehabilitation exercises are recommended in the nonoperative and postoperative treatment of biceps-related disorders and superior labrum anterior-posterior (SLAP) lesions in overhead athletes, a progressive exercise protocol with controlled low to moderate loads on the biceps has not yet been described.

PURPOSE

To describe a continuum of exercises with progressive low to moderate loads on the biceps based on electromyographic (EMG) analysis.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Using surface electromyography, the EMG activity of 8 muscles (upper [UT], middle [MT], and lower [LT] trapezius; serratus anterior [SA]; anterior [AD] and posterior [PD] portions of the deltoid; and biceps [BB] and triceps [TB] brachii) was measured in 32 healthy participants performing 16 commonly described shoulder rehabilitation exercises.

RESULTS

Of the 16 exercises, 13 (side-lying shoulder forward flexion, prone extension, seated rowing, serratus punch, knee push-up plus, internal and external rotation both in 20° and 90° of abduction, forearm supination, uppercut, and internal and external rotation diagonal) showed low (<20% maximal voluntary isometric contraction [MVIC]) EMG activity in the BB, and 3 (forward flexion in supination, full can, and elbow flexion in forearm supination) showed moderate (20%-50% MVIC) activity. None of the exercises elicited high (>50% MVIC) EMG activity. Based on the results, a ranking was calculated of the exercises, with mean EMG levels between 2.2% ± 1.24% (during internal rotation against resistance in 90° of shoulder abduction) and 35.9% ± 18.82% (during forward flexion in external rotation and supination) of MVIC.

CONCLUSION

This study describes a continuum of exercises with an increasing level of EMG activity in the BB. Exercises targeting the trapezius resulted in less loads on the biceps compared with exercises for the SA. In addition, exercises with an internal rotation component showed low activity in the BB. In general, the exercises meant to target the BB showed the highest levels of activity in the BB.

CLINICAL RELEVANCE

These results may assist the clinician in the appropriate choice of exercises in a graded rehabilitation program of biceps-related injuries.

Critical reflection of the advanced rehabilitation of an elite rugby league player sustaining a posterior Bankart lesion

The following is a critical description and discussion of the successful assessment and rehabilitation of a right shoulder posterior Bankart repair in an elite rugby league player. The rehabilitation follows accelerated, goal based guidelines, widely adopted in current sports practice but not well documented in the literature (Funk & Snow, 2007; Park, Lin, Yokota, & McFarland, 2004). The study serves to be the first critical discussion of such a regime.