Todd S. Ellenbecker, DPT, MS, SCS, OCS

Humeral Resurfacing Hemiarthroplasty With Meniscal Allograft in a Young Patient With Glenohumeral Osteoarthritis

STUDY DESIGN: Case report. BACKGROUND: Management of glenohumeral joint osteoarthritis in young, active patients is challenging due to the significant functional limitations and progression of the disease, coupled with the limited lifespan of prosthetic implants presently in use. The purpose of this report is to present the detailed rehabilitation program and outcome of a patient who suffered an initial glenohumeral dislocation and, following multiple surgical interventions, required shoulder hemiarthroplasty and biologic glenoid resurfacing to return to function. CASE DESCRIPTION: An objectively based rehabilitation protocol was used for this patient following shoulder hemiarthroplasty. Data collected included passive and active range of motion, isometric rotational strength, and functional outcome scores to include the Single Assessment Numeric Evaluation (SANE) and American Shoulder Elbow Surgeons (ASES) outcome measures. OUTCOMES: Progressive improvements in active and passive range of motion were documented at numerous points during postoperative rehabilitation, including 1 and 2 years postoperatively. The patient's initial functional outcome scores improved from 2/100 to 90/100 in the SANE and from 17/100 to 85/100 for the ASES rating scales. At 2 years postsurgery the SANE score was 60/100 and ASES 68/100. DISCUSSION: Early postoperative range of motion exercises performed in a range protecting the subscapularis, coupled with a progressive program of rotator cuff and scapular strengthening exercises, resulted in decreased pain, improved range of motion, and return to work in a limited capacity following hemiarthroplasty with biologic glenoid resurfacing. Further research in series of patients following this procedure will help to establish optimal treatment guidelines and prognosis for young active patients with severe glenohumeral joint osteoarthritis. LEVEL OF EVIDENCE: Therapy, level 4.J Orthop Sports Phys Ther. 2008;38(5):277-286, published online 22 January 2008. doi:10.2519/jospt.2008.2546KEY WORDS: arthroplasty, biologic resurfacing, rehabilitation, shoulder

Assessment of Shoulder Strength in Professional Baseball Pitchers

Study Design: A bilateral comparison of strength and range of motion testing in professional baseball pitchers. Objective: We studied 39 professional male baseball pitchers to determine if the shoulder used for throwing was weaker or had less passive range of motion, compared to the nondominant arm. Background: Shoulder muscle weakness has been proposed as a possible risk factor for developing injury. Therefore, objective quantification of the strength of glenohumeral and scapular rotator muscle groups should be studied in a population of professional baseball pitchers. Methods and Measures: Passive internal and external range of motion was bilaterally measured at 90° of abduction. Muscle strength of the following muscles was measured bilaterally with a hand-held dynamometer: external and internal glenohumeral rotators, supraspinatus, middle trapezius, lower trapezius, and serratus anterior. Results: Passive external rotation of the glenohumeral joint at 90° of abduction on the pitching side was significantly greater than on the nonpitching side. Passive internal rotation range of motion on the nonpitching side was significantly greater than on the pitching side. The pitching arm’s internal rotators, when tested in abduction, were significantly stronger than the nonpitching arm. The nonpitching arm’s external rotators in the plane of the scapula, and in abduction, were significantly greater than those of the pitching arm. The pitching arm’s middle and lower trapezius muscles were significantly stronger than those of the nonpitching arm. Conclusion: The range of motion and strength characteristics measured in this study can assist clinicians in evaluating athletes who use overhead throwing motions. J Orthop Sports Phys Ther. 2000;30(9):544-551. Key Words: professional baseball pitchers, rotator cuff strength, scapular muscle strength

Report Testing Isokinetic Muscular Fatigue of Shoulder Internal and External Rotation in Elite Junior Tennis Players

Study Design: Single group, posttest only descriptive analysis of isokinetically measured shoulder internal and external rotation muscular fatigue. Objectives: To determine whether differences in isokinetically measured muscular fatigue exist between shoulder external (ER) and internal rotation (IR) and between the dominant (DOM) and nondominant (NDOM) extremity in elite junior tennis players. Background: The importance of the rotator cuff in stabilizing the humeral head during repetitive athletic overhead motions has been identified in biomechanical investigations. The application of exercise to improve muscular function of the shoulder and prevent injury is a common practice in physical therapy, but shoulder fatigue in tennis players has received little attention in the literature. Methods and Measures: Seventy-two elite junior tennis players (ages 12 to 18) underwent bilateral isokinetic testing with 90° of glenohumeral joint abduction. A muscular fatigue protocol consisting of 20 maximal-effort concentric contractions of ER and IR was used to measure muscular fatigue at 300°/s. A relative fatigue ratio was calculated by dividing the work in the last 10 repetitions by the work in the first 10 repetitions. Higher fatigue ratios indicate improved muscular fatigue resistance. A 2 x 2 ANOVA was used to assess differences in fatigue in DOM versus NDOM arm, and in IR versus ER. Results: Relative muscular fatigue ratios for ER and IR were 69.1 ± 15.3% and 82.93 ± 14.81% for the DOM extremity, respectively. In the NDOM extremity, ER and IR fatigue ratios were 71.13 ± 15.07% and 83.9 ± 16.5%, respectively. These results indicate significant differences between the fatigue ratios for ER and IR. No significant difference between extremities in either ER or IR relative fatigue ratios was found. Conclusions: These data have implications for rehabilitation and conditioning of the rotator cuff musculature. J Orthop Sports Phys Ther. 1999;29(5):275-281. Key Words: shoulder, muscular fatigue, tennis

Glenohumeral Joint Range of Motion and Rotator Cuff Strength Following Arthroscopic Anterior Stabilization With Thermal Capsulorraphy

Study Design: Single-session, posttest only, descriptive analysis of range of motion (ROM) and strength. Objectives: To measure ROM and strength approximately 12 weeks following arthroscopic anterior stabilization of the glenohumeral joint with thermal capsulorraphy. Background: Treatment of the patient with anterior, unidirectional glenohumeral joint instability often includes surgical stabilization. Current methods focus on arthroscopic stabilization and early ROM and strengthening to restore normal function to the upper extremity. Methods and Measures: Twenty patients diagnosed with unidirectional shoulder instability (mean age 24.5 years, SD = 8.48) underwent a postoperative rehabilitation program following unilateral arthroscopic shoulder stabilization with thermal capsulorraphy. Objective testing including ROM and isokinetic internal rotation (IR) and external rotation (ER) strength at 90, 210, and 300 degrees/s was performed 12 weeks postoperatively. Results: Ten patients had a complete return of shoulder flexion ROM at 12 weeks. There were deficits compared to the noninjured extremity in postoperative glenohumeral joint mean abduction (9.8 ± 12.7 degrees), IR (8.4 ± 15.0 degrees), and ER (13.1 ± 14.4 degrees). Isokinetic testing showed a complete return of ER strength on the postoperative extremity compared to the uninjured extremity for 12 patients with a 4% (± 21.1%) mean deficit measured in IR strength at the slowest testing velocity. No significant difference was found between extremities in the external/internal rotation ratios. Conclusion: Postoperative rehabilitation emphasizing progressive ROM and rotator cuff and scapular strengthening has produced favorable results in patients 12 weeks postoperatively with respect to glenohumeral joint ROM and IR and ER strength. Further research and follow-up is required to obtain long-term outcomes with respect to patient satisfaction and stability of the glenohumeral joint following this arthroscopic procedure. J Orthop Sports Phys Ther. 1999;29(3):160-167. Key Words: shoulder, instability, isokinetics

Concentric Isokinetic Shoulder Internal and External Rotation Strength in Professional Baseball Pitchers

Objective measurement of shoulder internal and external rotation strength is an important part in the comprehensive evaluation and rehabilitation of athletes who perform predominantly unilateral upper extremity movement patterns. Apparatus- and population-specific descriptive data are needed to enhance the interpretation of results from isokinetic dynamometers. The primary purpose of this study was to measure isokinetically glenohumeral joint internal and external rotator peak torque and work in professional baseball pitchers and determine whether significant differences exist between the dominant (throwing) extremity and nondominant extremity. One hundred twenty-five healthy professional baseball pitchers were tested bilaterally on a Cybex 300 series isokinetic dynamometer at 210 and 300°/sec for concentric internal and external rotation of the glenohumeral joint with the arm in 90° of abduction. A standardized protocol and testing guidelines were strictly followed. A dependent t test was used to test for differences between extremities for peak torque and single repetition work isokinetic parameters. No significant difference between the dominant and nondominant shoulder was found for external rotation peak torque or single repetition work at either testing speed. Significantly greater (p The results of this study are important for the application and interpretation of isokinetic data on unilaterally dominant upper extremity athletes. The use of a population-specific, descriptive isokinetic data profile is important in both rehabilitation and prevention of shoulder injuries. J Orthop Sports Phys Ther. 1997;25(5):323-328. Key Words: shoulder, baseball, dynamic muscle strength

Glenohumeral Joint Internal and External Rotation Range of Motion in Elite Junior Tennis Players

Objective measurement of range of motion of the glenohumeral joint is important for the rehabilitation and prevention of shoulder injury. The primary purpose of this study was to determine whether significant differences exist between the dominant (tennis playing) and nondominant extremity in active internal and external rotation range of motion in elite junior tennis players 11-17 years of age. Two hundred three elite junior tennis players (113 males, 90 females) were bilaterally measured for internal and external rotation at 90° of abduction in a supine position with a specific methodology attempting to isolate glenohumeral motion, while minimizing or negating scapulothoracic motion. A standard universal goniometer was utilized to measure active range of motion (AROM). Dependent t tests were used to compare differences between extremities. No significant difference was found for males or females between the dominant and nondominant arm in external rotation. Analysis of internal rotation (AROM) differences showed significantly less (p < .001) internal rotation (AROM) on the dominant arm for both males and females. Significantly less (p < .001) dominant arm total rotational range of motion was also found in both males and females. The loss of dominant arm internal rotation (AROM) has clinical application for both the development of rehabilitation and preventative flexibility/range of motion programs. J Orthop Sports Phys Ther. 1996;24(6):336-341. Key Words: shoulder, joint motion, tennis

Descriptive Report of Shoulder Range of Motion and Rotational Strength 6 and 12 Weeks Following Rotator Cuff Repair Using a Mini-Open Deltoid Splitting Technique

Study Design: Retrospective chart review.Objectives: To measure short-term postsurgery glenohumeral internal rotation and external rotation strength, shoulder range of motion (ROM), and subjective self-report ratings following mini-open rotator cuff repair of full-thickness rotator cuff tears.Background: Physical therapists provide rehabilitation for patients following mini-open rotator cuff repair. Long-term outcome studies have reported a high percentage of good and excellent results following surgery; however, little has been published regarding the immediate short-term results of this procedure, during which the patient is under the direct care of the physical therapist.Materials and Methods: Charts from 11 female and 26 male patients, with a mean ± SD age of 57.3 ± 9.9 years, were reviewed following rotator cuff repair, using an arthroscopically assisted mini-open deltoid-splitting approach. All patients underwent postsurgery rehabilitation by the same therapist using a standard protocol. Retrospective chart review was used to obtain descriptive profiles of shoulder joint ROM at 6 and 12 weeks postsurgery and isokinetically assessed shoulder strength at 12 weeks postsurgery.Results: For the postsurgical shoulder, ROM deficits ranging between 5° to 7° were measured for shoulder abduction and external rotation and internal rotation at 90° of abduction. The postsurgical extremity had greater flexion ROM (9°) compared to the contralateral side. Isokinetic external rotation strength deficits of 5% to 7% were present at 12 weeks postsurgery, with 2% to 11% greater internal rotation shoulder strength on the operative extremity, when compared to the other side. Patients completed the self-report section of the modified American Shoulder Elbow Surgeons (ASES) Rating Scale at 12 weeks postsurgery and scored a mean of 38.7/45.0 points.Conclusion: The application of early ROM and progressive strengthening following mini-open rotator cuff repair allows for the successful return of ROM and strength 12 weeks postsurgery. The results of this study provide objective data for both shoulder ROM and strength at time points during which patients are traditionally receiving physical therapy following surgery. J Orthop Sports Phys Ther. 2006;36(5):326-335. doi:10.2519/jospt.2006.2191Key Words: glenohumeral joint, rotator cuff tear, surgery

Postsurgical Rehabilitatiojn Protocols When the Evidence Is Limited