RETURNING TO GOLF AFTER ROTATOR CUFF REPAIR a systematic physiological and kinesiological approach

1. RETURNING TO GOLF AFTER ROTATOR CUFF REPAIRa systematic physiological and kinesiological approach William Bryan,MD Associate Professor Weill Medical College of Cornell University The Center for Orthopedic Surgery Methodist Hospital Houston, Texas

2. Golfers and rotator cuff tears • The kinesiology of shoulder function as it relates to golf • The myriad of shoulder conditions brought to and caused by golf • Rotator cuff tears and surgery • An accelerated program to return to the game

3. Bilateral shoulder muscle activity studied with indwelling electrodes and high speed film • Deltoid is incredibly inactive except on left just preceding ball contact • Left and right supraspinatus/infraspinatus fired at low level through swing • Subscapularis was active throughout swing • Latissiumus dorsi and pectoralis major provided power

4. Eight shoulder muscles groups were studied with indwelling electrodes • Well known that men are overall 40% stronger and hit the ball further • What was contribution of shoulder musculature • Women tended to have more activity during takeaway and forward swing • Men tended to have more activity during acceleration and follow-through (?deacceleration effort?) • All Tours have similar incidences of shoulder problems

5. Golf is not considered an overhead sport but in college and middle-age groups over 30% of the swing is spent vertically elevated above 90 degrees • The combination of horizontal and vertical extremes has been shown to be a mechanism for shoulder injury –particularly with the number of repetitions during play and practice

6. Seniors showed in right shoulder 28 degrees less external rotation than college players • On left side 21 degrees less external rotation • Reduction in vertical planes as well – 18 degrees less on right and 21 degrees on left

7. The increased right-side horizontal abduction seen in seniors may be a strategy used by proficient golfers to compensate for reduced shoulder turn. • By bringing the right arm farther back at PK, older golfers may be able to increase the arc of the backswing without having to increase the amount of shoulder turn or axial rotation of the spine.

8. In their experience a multitude of shoulder problems showed up in their clinic which hampered the ability to play golf

9. GOLFING PATIENTS BRING OTHER SHOULDER PROBLEMS TO THE GAME • Younger, more aggressive male golfers and ligamentously loose female players can develop posterior shoulder subluxation instability

10. SLAP TEARS ARE THE RESULT OF REPETITIVE OVER-HEAD THROWING,VIOLENT ABDUCTION EXTERNAL ROTATION INJURY,OR INCIDENTALLY SEEN ON MRI IN OTHER PATIENTS GOLFING PATIENTS CAN BRING OTHER SHOULDER PROBLEMS TO THE GAME

11. Glenohumeral arthritis is a slowly progressive condition sometimes precipitated by history of traumatic injury,rotator cuff deficiency, or just plain genetics GOLFERS CAN BRING OTHER SHOULDER PROBLEMS TO THE GAME

12. AC joint arthritis stems from history of heavy weight-lifting,AC joint grade I or II separations,occupations demanding cross-body action, or just bad luck GOLFERS CAN BRING OTHER SHOULDER PROBLEMS TO THE GAME

13. RETURNING TO GOLF AFTER ROTATOR CUFF REPAIRa systematic physiological and kinesiological approach William Bryan,MD Associate Professor Orthopedic Surgery Cornell Weill College of Medicine Methodist Hospital Houston, Texas

14. SEVERITY OF TEAR DEPENDS ON ANATOMICAL INVOLVEMENT • Supraspinatus • Infraspinatus • Subscapularis • Biceps tendon dislocation

15. Our approach is like most “fly under the radar” Cortisone shots Physical therapy If this fails treat as a full-thickness tear and repair Often seen as a part of the “baggy-saggy rotator cuff degeneration scene PARTIAL UNDERSURFACE ROTATOR CUFF TEAR

16. Beware These intrasubstance tears often harbor calcium deposits which somehow are unbelievable pain generators Seen along with general attenuation of cuff…… “the baggy-saggy rotator cuff degneration scenario” May need excision and tendon retensioning INTRASUBTANCE ROTATOR CUFF TEAR

18. Amazing how some folks can tolerate this situation MRI will show the presence or absence of muscle atrophy There are no bridging tissues available Patients will decreased sensitivity to rotator cuff pathology will probably re-tear any surgical effort RETRACTED FULL-THICKNESS TEAR

20. Mechanically enhanced rotator cuff repairs have allowed for aggressive rehabilitation

21. Of 30 golfers…… all but three returned to play golf after acromioplasty and rotator cuff repair • 23 were playing at their previous competitive levels . No significant differences in driving distances or handicaps

22. Making golf drills and skills part of the rehab program –keeping the player in the game • Physical therapist must understand the game • Pt must have a knowledge of commonly practiced drills and the sundry apparatti used to hone the swing • Pt clinic must accept the use of these devices and incorporate golf specific activities in clinic

23. Basic science would argue against early activity

24. Localized key extracellular matrix proteins and growth factors at the healing tendon-to-bone insertion site in the early stages of healing • Did histology of healing tissue • Collagen type I and III and TGF-beta1 and TGF-beta3 • Early period of intense cellular activity,differentiation, and growth factor production • Healing tissue was less organized than uninjuried tendon and more like scar tissue being remodeled

25. Rotator cuff tears created and repaired in rats • Post-operative activity controlled • Activity had no effect on elastic properties at four weeks but decreased activity had a positive effect at sixteen weeks • Decreased activity therefore improved the quality of repaired tissue by letting collagen become better organized and thus improving mechanical properties

26. The advanced course-customizing rehab Based on the nature of the cuff tear • The anterior supraspinatus tear • The acute non-retracted supraspinatus tear—he’s confident that you could start earlier ER and IR with this but the info is rarely given • Chronic supraspinatus-infraspinatus tears • Holland emphasizes this as well—not just size of tear, but location—this must be part of the dialogue between PT and physician..part of the lost in translation cycle. http://www.youtube.com/watch?v=cUt7JmUIix4

27. The first two weeks after rotator cuff repair • Avoid excessive internal rotation and extension • Passive external rotation in several planes • Promote “out of immobilizer time” for firing of shoulder support muscles • Active-assist flexion

28. The first two weeks-how the physician maximizes effort Get out of immobilization and start circumduction Medicate liberally hydrocodone anti-inflammatory meds ultram ?Lyrica? Spell alphabet on table surface Rest hand on high surface and move away

29. Proficiencies Needed at 0-14 days

30. The second two weeksafter rotator cuff repairbeyond acute pain • Patient should be comfortable enough for spine rotation and opposite shoulder strengthening –stretching

31. The second two weeksafter rotator cuff repairbeyond acute pain—THE DO’S • active assisted internal and external ROM in scapular plane—fire cuff but w/o undue stresses • Passive ROM to stretch and lengthen tissues • Rhythmic cuff exercises , full passive ROM at wk 4 and external rotation at 90 degrees at week 4

32. The second two weeksafter rotator cuff repairbeyond acute pain—THE DO’S • Rhythmic stabilization at 30º abduction hands on with PT or family member (and if possible supine flexed at 135 bc deltoid centers humerus) • Work on flexion, but avoid eccentric contraction – tensile and structural properties can take a hit

33. The second two weeksafter rotator cuff repairbeyond acute pain THE DON’TS!!! • overload tendon! • resistance too soon!

34. Proficiencies Needed at 21+ days

35. Progressing at 3-4 Weeks

36. Progressing at 3-4 Weeks

37. Progressing at 3-4 weeks: Golf drills • One-handed putting with non-involved arm • Two–handed putting • Putting “through the lane”—lining up shots—use string instead of clubs

38. Month One—Recapturing the Swing

39. Second month: acceleration and turning the corner • Short game strokes and ball hitting (end of second) Patient needs normal GH mechanics for this to start—good functional test: 2 lb weight to 160 normal motion –see slide) • Increase shoulder stretching (golfer needs normal motion) • Active assist in all planes

40. The second month after rotator cuff surgeryturning the corner golf toys • Putting • On plane assist devices • Regroove mid-swing plane with wedges

41. The second month after rotator cuff surgeryturning the corner golf toys • Illogic of weighted club: • Momentum= mass* velocity • Velocity is the more important of the two, because the distance a golf ball travels is approximately proportional to square of initial velocity • Mass gained is likely more than offset by velocity lost due to heavier club

42. The second month-what’s happening “inside” • If not on track with close to full motion at 4-5 weeks, then lots of stretching (structural tightness(shoulder scarring down) • Is patient armed with several activities away from the clinic to promote stretching ---Hourly!!!!!!!!! • It is now that we are depending on the mechanical repair………. Not biological,yet

43. Turning the cornerthe second month after rotator cuff repair • Essential general benchmarks must be met: • Must reestablish rotator cuff’s ability to control the humeral head • Restore full passive motion • Emphasize muscular balance of RC so it can keep humeral head centered as we enter flexion, especially external rotator to internal rotator strength

44. Turning the Corner

45. Second Month turning the corner Acceleration

46. Getting blindsided during rotator cuff repair rehabilitation • Wound inflammation • Unexpected pain • Clicking and popping • Prolonged weakness

47. Turning the cornerthe second month after rotator cuff repair • Benchmarks specific for return to golf: • Normal, pain-free ROM • RC strength at least 80% of uninvolved side • Great diagnostic: • Active forward elevation with two pound weight • Patient needs to achieve 160°-180° without “cheating”—no shrugs, bends to elevate weight

48. Warning signs during month 2-turning the cornerwhen to slow down rehab • What are the basic proficiencies that Matt Holland and the Physiotherapy Associate PTs want to see before allowing progressive golf activities– • Cuff strength must be at least 80% of uninvolved side • Normal pain free motion • What alarms Matt?? • Stiffness, pain, or even weak but painless ROM of concern • How does he get patient back up to speed— • Move backward to move forward

49. Second monthturning the cornerGetting Back in the Game

50. Second monthturning the cornerbringing golf to the physical therapy clinic