Continuing Education Bits for PTs & PTAs

Archive for February, 2012

So… off to a Reverse Total Shoulder (rTSA)

Two quick paragraphs as a prelude to the next steps in the Case:

  1.  Once again, I have to start off by saying how impressed I am with your thought processes and professionalism.  I’ve received many private emails from PTs who are learning from all of you who comment (as a matter of fact, the over 2,000 page views within the first 24 hours of posting indicates people are really interested in what you have to say!)
  2. I’m going to interject a wee bit about myself here:  while I am very comfortable with the shoulder (especially with sports and biomechanics) I am BY NO MEANS an expert in the kind of case presented here.  This case was purposefully selected so the YOU have a place to educate all of us.  So, Thanks, on behalf of all of us PTs!

Now, back to the Case:

As many of you wrote, the MRI indicated a need for referral to an orthopaedic surgeon who performs rTSAs.  The reverse total shoulder is a ‘last chance’ procedure for folks without much rotator cuff.  And, Mr. G. clearly was lacking in the rotator cuff department.  Candidates for the rTSA need to be medically sound and have demonstrated precise follow-through to instructions/limitations post surgery.  Because if something happens to the rTSA, there is no re-do —- there is no second chance with it.

The rTSA entails the ‘ball’ of the socket to be inserted into the scapula and the ‘dish’ of the joint into the humerus (you can see that in the x-ray above – and some of the references below give even clearer pictures).

This is a relatively new procedure and Mr. G. was encouraged to interview multiple surgeons, ask about the number of rTSA procedures each surgeon performs and the outcomes.   Fortunately for Mr. G., one of the surgeons is a leader in the field of rTSA, a member of the American Shoulder and Elbow Surgeons, has performed research, does over 160 rTSA’s/year and has excellent outcomes.  Dr. Itamura is an Associate Professor of Clinical Orthopaedic Surgery at the University of Southern California  School of Medicine, Department of Orthopaedics.  Operating room staff and therapy staff also recommended Dr. Itamura without reservation.

Here is a word from his surgeon, Dr. John Itamura:

Mr. G. was an ideal candidate for the rTSA.  First of all, he is medically sound.  This is a difficult procedure and if he had had medical co-morbidities, I would not have done the procedure on him.  Secondly, his lack of rotator cuff make the rTSA the most viable procedure.  Third, he has had other total joint replacements, so he knows what it will take to get back on the road.  He is aware that it will take a year before we know exactly how far he will progress.  Fourth, he listens.  I believe he will be very conservative and careful with his reconstruction.  Even though he is basically an over-achiever with exercise, the consequences of that have been explained to him and he agrees not to overdo things.  He knows there is no second chance at this point. 

I’m not a big proponent of PT for the rTSA, since conservatism is the route I go. And if the patient does receive PT, it HAS to be slow, easy and the patient must listen carefully to the therapist – so, we’d need to all be on the same page. I have my patients perform the Anterior Deltoid Exercises for Patients with Massive Rotator Cuff Tears 5 times a day (the reference for that is below). Yet, I know other excellent surgeons are more aggressive. Boudreau et al 2007, JOSPT (which is not research, but a Clinical Commentary) is much more aggressive than I choose to be at this point, and there are surgeons who go that route.  But, give me some evidence, and I’m happy to reconsider — I may do some research on the rehab myself!

For four weeks post-op, Mr. G. wore an abduction splint (image above), even at night.  After 4 weeks in the splint, here is the resting position of his arm (image below).  At 6 weeks post op, his arm had naturally dropped to < 10 degrees of abduction.

physical therapy continuing education shoulder deltoid shortening

Now, as a member of American Shoulder and Elbow Surgeons myself, I see a huge difference in rehab opinions even among this specialized group of orthopaedic surgeons.  However, in my simple opinion, I’d still like to do some work on Mr. G.’s scapular stabilization.  So, once again, armed with literature, Dr. Itamura and I are scheduled to meet the end of this month.  We will discuss scapular mechanics, the effect of lack of scapular stabilization (Dr. Jacquelin Perry calls it a ‘floating scapula’) on the axis of rotation (and how that may affect the longevity of the prosthesis as well as the success of the outcomes), the probable fact that Mr. G. has been using his anterior deltoid (hence ‘retraining’) in place of his rotator cuff for years (thus some questionability about the ‘anterior deltoid’ retraining as seen in www.readingshoulderunit.com) and the potential for precise, practical, low risk scapular exercises for Mr. G. – and all folks receiving a rTSA.  Dr. Itamura and I may actually do some research on this since I suspect Mr. G. is not alone – that most rTSA candidates have been ‘re-educating’ their deltoids for awhile and I’d hypothesize that a large percentage of these patients have a ‘floating scapula’ (i.e. not enough scapular stabilization to allow for precision in the axis of rotation with humeral motion.)

So, we will see where that goes!

Here are some articles available for you regarding the rTSA. Unfortunately, there is very limited evidence based information out there (probably because the procedure is relatively new – it was performed in Europe for about 20 years before it was approved by the FDA in the United States). These articles are available for free as part of the physical therapy continuing education resources at EDUCATA’s library. You will need to log in, but membership is free too.

  1. Consequences of scapular anatomy for reversed total shoulder arthroplasty
    By: Middernacht B, De Roo PJ, Van Maele G, De Wilde LF.
    Clin Orthop Relat Res. 2008 Jun;466(6):1410-8.
  2. Contribution of the reverse endoprosthesis to glenohumeral kinematics
    By: Bergmann JH, de Leeuw M, Janssen TW, Veeger DH, Willems WJ.
    Clin Orthop Relat Res. 2008 Mar;466(3):594-8.
  3. Evolution of the reverse total shoulder prosthesis
    By: Jazayeri R, Kwon YW.
    Bull NYU Hosp Jt Dis. 2011;69(1):50-5.
  4. Reverse shoulder arthroplasty
    By: Smithers CJ, Young AA, Walch G.
    Curr Rev Musculoskelet Med. 2011 Dec;4(4):183-90.
  5. Rotator cuff deficient arthritis of the glenohumeral joint
    By: Macaulay AA, Greiwe RM, Bigliani LU.
    Clin Orthop Surg. 2010 Dec;2(4):196-202.
  6. Total shoulder arthroplasty
    By: Sanchez-Sotelo J.
    Open Orthop J. 2011 Mar 16;5:106-14.
  7. What is a successful outcome following reverse total shoulder arthroplasty?
    By: Roy JS, Macdermid JC, Goel D, Faber KJ, Athwal GS, Drosdowech DS.
    Open Orthop J. 2010 Apr 23;4:157-63.

Additional resources include the following two articles as well as the exercises that Dr. Itamura utilizes.

http://www.jshoulderelbow.org/article/S1058-2746(08)00429-1/abstract

Boudreau, S, Boudreau E, Higgins LD, Wilcox RB 3rd: Rehabilitation Following Reverse Total Shoulder Arthroplasty.  JOSPT, 37(12), 2007, 734-743

www.readingshoulderunit.com which is out of England and I think the exercises are there under  Physiotherapy.

All right – it’s YOUR TURN again!  I love reading your posts! What do you think should be done next?

Marilyn

Coming next week: Mr. G. discusses the outcome of his treatments and present condition

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Shoulder Case Study #1: MRI results

Oh, Mr. G.  Not a pretty arm!

As many of you have mentioned, I too believed in the need for imaging tests and/or a referral to Ortho. I wanted anatomical knowledge BEFORE going down the wrong road (and using up his Medicare visits). There were way too many unknowns and the patient has a complex musculoskeletal history.

Thank-you, Dr. McFarland, for your viewpoint. You are a well respected (and well published!) orthopaedic surgeon with an excellent reputation with the shoulder. So, all of us PTs appreciate your unique input.

This case introduction was purposefully written with limited assessment information in order to see what YOU WOULD DO: to pull out your thought process with not only the assessment, but with the next steps. And your comments demonstrate a high degree of skill of which our profession can be proud. So thanks for filling in the intentional blanks so that your thought process can be a learning tool for all PTs –and given the number of visits to this blog, many have benefited from hearing from you!

Onward to what happened next. I did go back to Mr. G’s internist and suggested an orthopaedic referral;  and with all due respect to an orthopaedist, my opinion was that there would be a benefit from an MRI. The internist agreed. So, armed with a list of questions, Alan set out to interview several orthopaedists with a specialty in the shoulder. Interestingly, not all of these surgeons thought an MRI  nor any other tests were necessary prior to deciding the course of action (and for Alan, that ruled them out as a candidate to be HIS orthopaedist). One of the surgeons made it very clear to Alan that he couldn’t say what he’d do until he had an MRI.

If any of you are interested in Alan’s interview questions for the orthopaedists – and what made him ultimately select the one he did, just ask on the comments section and I’m sure the patient will be happy to respond to you.

Here are the results of that MRI:

EXAMINATION:  MRI OF RIGHT SHOULDER WITHOUT CONTRAST — CONCLUSIONS:

  1. The supraspinatus tendon is torn with approximately 5 cm of proximal retraction of the musculotendinous junction.  Severe fatty atrophy is seen of the supraspinatus muscle (please see the MRI image, above).
  2. A high-grade partial tear is seen of the distal infraspinatus muscle predominately involving the joint side surface and this involves greater than 80% of the thickness of the infraspinatus tendon.
  3. The subscapularis tendon reveals severe tendinosis with thickening.
  4. Joint effusion is present with a large amount of fluid extending into the subacromial/subdeltoid space with distension of the subacromial/subdeltoid space.  The distension also extends anteriorly to involve the subcoracoid bursa.  Extensive synovial thickening is seen superior to the humeral head in the region of the supraspinatus tendon tear.
  5. The bones are notable for severe subchondral cystic changes involving the articulating surface of the humeral head, as well as the glenoid.  Denudation is seen of the articular cartilage with subchondral eburnation and large marginal osteophytes.  The entire labrum is severely degenerated..

OK – back to YOU — WHAT ARE YOU THINKING?

Shoulder Case Study, additional detail

Dear Joanne S. , Brenda and all others participating in this blog,

Thanks for your interest and comments regarding my shoulder condition–I have to periodically remind myself you are talking about me. For a person whose background has been in marketing and management, this exercise is new, refreshing and informative.

I would like to give you a little bit more info: during my yearly physical. my doctor gave me a copy of the book “Younger next Year” which extols the virtues of exercising 6 days a week for the rest of your life–it was like preaching to the choir. I have always been active and “worked thru” knee replacements, a rt hip, two back surgeries etc.

Prior to my shoulder acting up (approx Oct of 09), I would swim 1 mile (overarm crawl) 3-4 days a week and then exercise in the gym (recumbent bike, weights, Pilates, tread mill etc. the alternate days for about 1 and a half hours). Throw in some nice 3 mile walks in the area and that was my routine. I felt great when I exercised and lousy when I didn’t. My weight has stayed around 190 lbs for 50 years although a bit of body fat is creeping in.

My shoulder symptoms bothered me enough to get an injection (depo medrol 40m) from a shoulder dr. on 2/23/01. I experienced a 40% reduction in pain and discomfort. In fact I was able to get back in the pool without any discomfort–at least for about 8 weeks when the discomfort returned. I got 2 more shots (kenlog 40m on 7/21/11  on 8/8/11), without positive results.

Yes, I do have a very high pain threshold, but during the fall of 2011, the pain reached 9 and 10 when my arm and shoulder were positioned wrongly. I could not raise my arm higher than 90 degrees, wash my hair, brush my teeth etc. Sleeping was near impossible unless I stayed very still on my back. I could place my arm straight down at my side or bent on my chest.

I had to back away from my workouts –other that short walks around the block– which was depressing. Meanwhile I had to finish my evening teaching at the university. I could no longer carry my heavy briefcase, so I used a 2-wheel luggage carrier. That helped somewhat, although it hurt my back which was acting up at the time (I had a back MRI last August and results were all OK).

I got to class early to put data on the board–you should have seen me writing with my left arm holding up my right! The class lasts 3 hours, so you could have imagined how I felt when I got home. When sitting a chair without any movement, I experienced no shoulder pain. Someone should have taken a picture of me using a can opener! Without my sense of humor and input from trusted friends, I’m not sure what would have happened.

Again, thanks for your thoughts and comments–please keep them coming and I’ll stay in touch.

Alan G.

What would YOU do?

H & P of CASE #1: A Case of the Shoulder

Alan G. is a 79 y.o male.  He is a University Professor and teaches at least 1 day/week (this teaching includes carrying briefcases and writing on a white board).

Mr. G is a very active gentleman.  He works out at least an hour a day, 6 days a week: he swam for the University as a student (in the days before googles!), continues to swim, bike, lift weights, use the elliptical, hike, takes Pilates twice/week, etc.  As a lay person, he has taken Dr. Avers EDUCATA lecture on Strengthening Principles for the Aging Adult, and one of his goals in life is to finally get to meet Dale — he LOVED that lecture.

Mr. G. is medically sound with no medical co-morbidities.  In the past decade he has had bilateral total knee replacements, unilateral total hip replacement, 2 levels (L3/4 and L4/5) lumbar laminectomies, 2 levels of cervical fusion C3/4 and C4/5.

He has a very high pain threshold, and anatomically generated pain that would be reported years earlier by other people, doesn’t even register for him.  Throughout his PT history, he has been asked to ‘listen for his pain’.  It appears that the lack of knowing of the pain has caused him more anatomical damage as opposed to if he had known it was hurting earlier.

Alan believes strongly in PT.  If anything, this individual does too much — never too little.

Alan was referred by his internist with R shoulder pain.  He reports that he can no longer carry his briefcase in his right hand nor can he lift his arm to write on the white board at school.  (Additionally, his back is bothering him again.)  Here is a brief summary of clinical findings:

  1. Shoulder pain of ‘10’ with active motion (and for this patient, that would be equal to about ‘100’ in another patient), pain at rest is ‘7’ and pain with passive motion is ‘8-9’.
  2. Total disruption of sleep – Alan is unable to sleep due to the pain and due to the fact that the pain mandates that he only sleep on his back (not his side)
  3. Marked atrophy in Supraspinatus
  4. Scapular winging (see image, below)
  5. Noted avulsion bilaterally of long head of biceps
  6. Strength and ROM
  7. Sensation is normal
MOTION AROM PROM STRENGTH
Flexion and abd 25 degrees 90 degrees F+
ER 5-10 degrees 90 degrees F
IR WNL WNL G

So, now it is YOUR TURN.  What would YOU do?

Hello!

Marilyn Pink

My name is Marilyn Pink. I am a physical therapist and one of the founders of EDUCATA, the leading physical therapy continuing education resource. I’m very excited to now welcome you to this Blog where we hope to expand on our interaction with you.

Over these last few years many of you have asked for Case Studies.  So, as of today, we’ll start a series on a shoulder patient. Over the next weeks, we will update you on the patient and you can interact and tell all of us what YOU WOULD DO!  You are most welcomed (encouraged!) to comment at every stage of the case development. Our goal is to see if we are helping to fulfill your educational needs.

These case studies will be posted on this Blog as well as on our Facebook page. If you like the idea, please leave us a message on Facebook (and ‘Like Us’ too please!)  We hope you will spread the word on this patient case involvement and spread the word to your colleagues so they can all join in.

Please follow us as we discuss this case and participate with us as we unravel the solution to this interesting situation.

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