ARTHROSCOPIC SUBACROMIAL DECOMPRESSION
Melanie McNeal, PT, CSCS, CFT
for patients of
DAVID LINTNER, MD
Patients with impingement who have not responded well to conservative treatment, which may include rest, steroid injections, and physical therapy, are candidates for this surgical procedure.
Impingement of the subacromial bursa and supraspinatus tendon under the coraco-acromial arch can be due to any of the following: overuse, weakness of the RC, weakness of the force couples that control scapular movement, and poor posture. The end result of these problems is the inability to position the humeral head within the glenoid correctly. As a result, the structures under the coracoacromial arch, namely the supraspinatus tendon, long head of the biceps, and subacromial bursa, are at risk to be impinged with movement. Common associated finding with impingement are posterior capsule tightness and scapulo-thoracic muscle weakness.
It has been found that 95% of all rotator cuff tears are the result of impingement. There are three phases of impingement and patients can usually be classified into one of these phases by their age. The first phase is edema and hemorrhage. Typically, patients are under the age of 25 and often participate in excessive overhead activities. This stage is reversible if detected and addressed. In stage two, fibrosis and tendinitis is present. Repeated mechanical inflammation causes the bursa to become thickened and inflamed. In this stage, OH activities are painful and restricted. Patients are typically between the ages of 25 and 40. This stage is not reversible without treatment. Stage three is a rotator cuff tear. Patients in this stage are usually over the age of 40. Biceps rupture and bone changes can also be present at this stage.
Arthroscopic decompression is a procedure in which the anterior-inferior aspect of the acromion is excised. The main goal is to free the tendons or bursa that are getting impinged.
The key following surgery is to first regain normal and full functional ROM. Once adequate range is attained, an aggressive RC strengthening program must be initiated. External and internal rotator strength must be gained below shoulder level initially in order for OH activities to be performed without difficulty. The force couples controlling the scapula must also be addressed with rehab as they have been shown to be inhibited with impingement and are thus expected to be weak following surgery.
In phase one, the general goals are to protect the surgical repair, initiate ROM to prevent adhesions and increase circulation, decrease pain and inflammation, and stress emphasis of HEP.
PROM is as tolerated for all planes
AROM is limited secondary to pain and weakness of RC – patient should be allowed to move in pain-free range without allowing for substitution.
The RC gets a better blood supply when the shoulder is slightly away from the body; therefore, advocate the use of a towel roll under the arm when in a resting position.
- Rope and Pulley – flexion, scaption, abduction
- Cane/wand AA flexion, ER
- Posterior capsule stretch
- Towel IR stretch
- Pendulum exercises for blood-flow to joint
- Passive stretching and pain-free joint mobs can be initiated immediately, emphasizing post and inferior capsule
- IR/ER T-band exercises
- Side-step holding t-band at neutral IR/ER for isometric resistance
- Biceps and triceps with t-band
- Scapular strengthening with t-band – rows, shrugs, punches
- Supine rhythmic stabilization progressing to SL and standing
- Supine PNF patterns
- Heat prior to Treatment
- Ice following exercise
Emphasize HEP – to be performed 2-3X/day to achieve full ROM
General goals in Phase Two are to gradually restore ROM, initiate active muscle contractions with a focus on regaining proper scapulo-humeral rhythm, begin to train joint proprioception, and continue with HEP.
The RC muscles are very small; therefore, we use lower intensities to isolate each muscle without recruitment from surrounding larger muscles. Focus on hypertrophy initially by high volume (V= Reps X intensity/weight). Following the hypertrophy phase, strength is the focus with lower reps and higher intensities/weight.
- Continue with above to achieve full ROM
- Can progress post cuff and IR stretch to sidelying position
- Initiate chicken wing ER stretch
- Continue with joint mobs and manual stretching
- UBE for warm-up
- Standing db routine: flexion, scaption, empty can, deceleration
- Continue with t-band and Cable column exercises for biceps, triceps, scapular stabilizers
- Initiate push-up progression – wall, counter, table, knees
- Plyometrics – ball toss (chest pass, OH soccer throw)
- Progress rhythmic stab exercises to standing and holding
- T-band for resistance
- Manual PNF and T-band PNF
- Ice as needed following exercise and at night
Key here is not allowing Upper trap compensation with dumbbell exercises – patient should only be allowed to lift arm as far as possible without compensating. A biofeedback can be used on the upper trap if needed to help teach neuro-muscular control.
The goals in this phase are to restore full active ROM, progress strengthening and scapular stabilization exercises, and initiate more functional drills into rehab program.
- Pt should have full ROM in all planes by 6-8 weeks
- Continue with above exercises and g-h and scapular joint mobilizations to gain full range
- Continue with strengthening exercises from previous phase
- increasing sets, reps, and intensity as able
- Prone dumbbell therex
- Progress push-up progression to floor and then with legs/feet on swiss ball
- Initiate IR/ER isokinetics
- Standing rhythmic stab with t-band or holding object as Resistance
- Single arm plyometrics- ball on wall, deceleration tosses, plyo toss
- Manual high speed PNF patterns; T-band PNF patterns
- ER high and low speed t-band at 90/90 position
- Lat pull-downs, shoulder press
- Ice as needed
Goals include regaining full functional strength, implementing functional or sports specific training, and establishing a progressive gym program for continued strengthening and endurance training.
- Continue from previous phase as needed
- Continue from previous phase increasing reps and intensity
- Initiate sports specific and functional activities
- Interval throwing program (consult MD first)
When patient returns to a gym program, he/she must be educated in proper lifting techniques to avoid impingement. This includes the following: performing military press and lat pull-downs in front of body rather than behind the head; limiting the range of motion when performing exercises such as bench press and flies so that the elbows never fall past the plane of the thorax; limiting range with deltoid abduction lifts to 90°.