Physical therapy after shoulder surgery.

Anatomy and function of the shoulder joint

The shoulder joint consists of the humerus(upper arm bone), scapula(shoulder blade) and clavicle(collarbone). The joint between the upper arm and shoulder blade is called the glenohumeral joint. The clavicle with the shoulder blade is the acromioclavicular joint. Another joint of the shoulder area is the scapulothoracic joint. This is the joint between the shoulder blade and the ribs. These joints allow the shoulder to move in many different directions. The shoulder contains many different muscles and tendons. The function of these muscles is to move and stabilize the shoulder during different daily movements. There are smaller muscles that are closer to the joint but also larger muscles that have a more powerful function. These small muscles are called the rotator cuff, these muscles are like a corset around the head of the shoulder. Anatomically, a distinction is made between a local muscle system and a global muscle system. Functionally, however, they largely have the same function. In a non-restricted shoulder, the glenohumeral capsule, the capsule around the glenohumeral joint is elastic, long and does not restrict the normal range of motion of the shoulder. The function of this capsule is to provide strength in the shoulder. Around the capsule is the labrum. In every joint, so also in the shoulder, there is synovial fluid, also called joint fluid. Synovium allows joint surfaces to move smoothly in relation to each other by minimizing friction.

Shoulder instability

The shoulder joint has the greatest range of motion in our body. This is because anatomically, the socket is very small and shallow compared to the relatively large shoulder head. To compensate, at the edge of the shoulder socket is the labrum (cartilage ring). The labrum creates a larger socket, so to speak, and sits like a suction cup on the head of the shoulder. Furthermore, the joint is strongly enveloped by joint capsule, ligaments and various muscles. Normally, this ensures sufficient stability in the shoulder during daily activities and sports.

Instability at the shoulder joint almost always comes from an accident or as a result of long-term overuse, such as in various sports where a lot of work is done in the end position of the joint. In an accident, depending on the force and direction of the trauma, damage can occur to, for example, the labrum, ligaments and possibly muscles. Since these together must ensure stability of the shoulder, the reduced functioning of one or more of these structures can cause problems. 

People who suffer from instability are dealing with a shoulder that dislocates (luxates) or tends to dislocate (sub-luxation). In many cases, this is due to the labrum. Overuse or trauma can cause a tear in this area, reducing the stability of the shoulder. Unfortunately, the labrum does not have the ability to repair itself. With surgery, the labrum can be sutured so that stability can be restored. In the medical world, this is called a labrum repair.

Rotator cuff rupture

The rotator cuff consists of 4 muscles; teres minor, supraspinatus, subscapularis and infraspinatus. It is a group of muscles whose main function is to rotate the shoulder and stabilize the shoulder head in its socket. Is most cases, a rotator cuff tear involves the supraspinatus muscle that has damage. After that, it more often involves the infraspinatus muscle. Ruptures in the other two muscles are rare. 

Often the tearing of muscles or tendons is due to an accident. With the rotator cuff, this is often the case as well. Again, too much impact from a fall, for example, can cause the muscles to tear. Even more often with the rotator cuff it is the case as a result of aging. The tendons are then of inferior quality and are less strong there is not necessarily a lot to happen for substantial damage to the tendons. Several scientific studies show that half of all people over the age of 60 have at least a partial rupture in one of the rotator cuff muscles. So it is also partly a normal phenomenon just like gray hair and wrinkles. These people were also pain-free. If the symptoms match an image on an ultrasound scan, for example, then the cause of the pain may well be a rotator cuff tear. Surgery for a cuff rupture depends on several factors such as age and daily strain. Also, the tendon tissue must be of good quality, otherwise a re-rupture is quite plausible. Indeed, as we get a little older we can generally get out of the way fairly well if we are missing one or more shoulder tendons. At younger ages, the situation is different. If a surgical approach is chosen, the goal is to return the tendon to its original position. If this is not successful, we can also choose to anchor the tendon in another place. 

Physical testing when a rotator cuff tear (partial) is suspected
When cuff rupture is suspected, the physical therapy examination comes in handy. Often with such a rupture, not much abnormality can be seen externally. Sometimes blue discoloration is visible if the symptoms arose after trauma. In the physical therapy examination, reduction of strength will be observed in directions related to rotations and/or lifting of the arm.

Internal rotation lag sign
This test is used to test the subscapularis muscle. The patient is asked to sit upright with the elbow at 90 degrees. The examiner brings the arm fully to endorotation (turning inward) and asks the patient to maintain this position. At the time the subscapularis is ruptured this will not work.

External rotation lag sign
This test tests the supraspinatus muscle and infraspinatus muscle. The starting position is the same as in the previous test. This time, however, the therapist turns the arm fully to exorotation (outward) and again asks to maintain this position. Again, inability to maintain this position gives a positive test result.

Empty can test
The empty can test involves testing the supraspinatus muscle. This test is performed with the arms 90 degrees abduction and turned fully inward. With the arms in the scapular plane, the examiner applies force to the arms in a downward direction. Inability to resist this resistance (and especially a difference between the two arms) gives a positive test result.

In addition to these specific tests, in many cases a general movement examination may also reveal an inability to perform certain movements or an abnormal movement pattern. If in doubt, additional testing can be requested to clarify. 

SLAP leasie

At the top, the biceps attaches to the top of the socket of the shoulder. More specifically to the glenoid which is part of the labrum. So when the attachment comes loose on this side, there can also be some damage to the labrum. This takes a lot of force. In some cases you can hear something snap during the accident. Moving the arm overhead is often very painful or even impossible. The pain is often at the front and top of the shoulder head. A SLAP leasia is not common. Also, the diagnosis is often missed because only keyhole surgery can really give a definitive answer. In general, we distinguish between 4 different types:

• Type 1 is a partial tear, so the tendon is still adhering to
• Type 2 is a complete tear at the top of the labrum
• Type 3 is a buckethandle tear, a piece of the labrum then potentially enters the joint space causing entrapment and irritation
• Type 4 is a buckethandle tear that continues into the tendon of the biceps

Should surgery be necessary, the biceps tendon can be reattached using an anchor, often at a higher elevation in the shoulder. After surgery you will be allowed little or no loading for 6 weeks to allow the anchor to grow back in properly. Movements will also have to be severely restricted and you will often be in a sling for large parts of the day. 2 weeks after surgery, some cautious movement is allowed under the supervision of a physical therapist. After 6 weeks the strength and capacity of the shoulder region will gradually be built up again.

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