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Alessandro GianniniGruppo Medico Isokinetic, FIFA Medical Centre of Excellence, Torino
Torino, 28 Novembre 2015
Return to sport after surgery for rotator cuff
repair
RTP where we are?Let's start talking about shoulder……
…….starting from the knee
RTP where we are?
Return to the same competitive level:- 42% in non professional
player- 81% in professional
player
ACL reconstruction
Rotator Cuff Repair
Return to the same competitive level:- 66% in non professional
player- 49.9% in professional
player“Incorporating routine screening for psychological responses that could hinder returning to sport into standard postoperative rehabilitation programmes may help clinicians identify athletes at risk of not returning to sport”
“One of the hypotheses to explain this is that certain psycological factors that are not usually evaluated couldplay a role in the return to sport”
RTP where we are?Lest’s go more in depth with this systematic review…- “When studies report results in terms of pain relief or
range of motion, the results are nearly all very good, even though most patientes do no return to play at the same level”
RTP where we are?Lest’s go more in depth with this systematic review…
- “This is important information because it shows that a professional player cannot count on surgical repair of the rotator cuff to retun him or her to a sport career at the same level”
- “No difference between full tear and partial tear»
Why is RTP so difficult?“The only way to mimic the forces of
a baseball throw is to actually…… throw a ball.”
Axe M et al . Sports Health, 2009
What is the magic behind the throwing?
More than just a game…We are not the fastest animal in nature…...and surely not the strongest one….
..but we are the best throwers!
The magic of throwing• Internal rotation around
long axis of the humerus is the larget contributior to projectile velocity
• This rotation can exceed 9,000°/sec
• Is the fastest motion that human body produces• Maximum angular velocity during 100m running (in the hip) is around 800°/sec• No muscles in human body is able to generate so much rotation power• Inverse dynamic shows, the shoulder produce a large period of negative work
How can it be possible?Many things to consider….
Kinetic chain
V4
V3
V2
V1
Vg=V1+V2+V3+V4
Energy storageHow can it be possible?
• the mass moment of inertia around the long axis of humerus cause the forearm and hand lag behind the accelerating torso
Energy storage
• During the arm-cocking phase, the throwers’ humeri externally rotation exceed by 57° the active ROM
• Elastic energy can account for more than 50% of internal humeral rotation work done
• As the cocking phase begins, large torques are generated by rapid rotation of the torso
• The positioning of the shoulder and elbow at this time increase the mass moment of inertia
Implications for rehabilitation
Phase 2-3: Special considerations
Recovery of strength
Ismoetric HHD:• 0-0: ER/IR ratio
>75%• 90-0: ER/IR ratio 90-
100%• 90-90: ER/IR ratio 60-
85%
Byram et al. AJSM 2010
Most of the work is done eccentricaly.
We need to test EccIR? Cools et al. KSSTA 2015
Recovery of pain free ROM
• <20° side diff for IR
• <10° side diff for Total ROMEllenbecker BJSM 2010
We need to test «forced» passive ROM?
Phase 4: Recovery coordination
Prospective study evaluating energy flow during the tennis serve and injury
C. Martin Am J Sport Med 2014
• Noninjured player have higher energy flow from trunk and upper arm during the early and midle cocking
• Injured player have higher energy flow from trunk during late cockingPlayers with poor energy flow must create more loads at
the most distal joints
«Optimal» temporal relationship
• Many different aspects to consider with some difference between different sport
Two important features
Shoulder horizontal adduction must start before the instant the shoulder exceed 90° of
external rotation
Two important features
Avoid «delayed» peak angular velocity trunk rotationMore or less at the 85% of the
service in tennisMartin C. Med Sci Sports Exerc. 2013
Interval Sports Program
A "Interval Sports Program" is a functional rehabilitation that SIMULATES sports.These program apply progressive forces to structures on the mend and serve to gradually bring the athlete to sports as safely and quickly as possible
Phase 5: Recovery of gestures
Monday Wednesday Friday
Week three
15 short irons20 med ironsRest 10 min5 long irons15 short irons15 med ironsRest 10 min20 chips
15 short irons10 med irons 10 long ironsRest 10 min10 short irons10 med irons5 long irons5 woods
15 short irons15 med irons10 long ironsRest 10 min10 short irons10 med irons10 long irons10 woods
Week four
15 short irons10 med irons 10 long irons10 drivesRest 5 minrepeat
Play 9 holes Play 9 holes
Week five
Play 9 holes Play 9 holes Play 18 holes
Recovery of gestures
INTERVAL GOLF PROGRAMMonday Wednesday Friday
Week one
20 putts15 chipsRest 5 min15 chips
25 putts15 chipsRest 5 min25 chips
20 putts20 chipsRest 5 min20 putts20 chips 10 iron of teeRest 5 min 10 chips5 iron of tee
Week two
20 chips10 short ironsRest 5 min10 short irons15 med irons(5 iron of tee)
20 chips15 short ironsRest 10 min15 short irons15 chips putting15 med irons
15 short irons10 med ironsRest 10 min20 short irons15 chips
5 weeks3 days at week
progressive introduction of more demanding
gestures
Monday Wednesday Friday
Week one
12 FH8 BHRest 10 min13 FH7 BH
15 FH8 BHRest 10 min15 FH7 BH
15 FH10 BHRest 10 min15 FH10 BH
Week two
25 FH15 BHRest 10 min25 FH15 BH
30 FH20 BHRest 10 min30 FH20 BH
30 FH25 BHRest 10 min30 FH25 BH
BH, backhand shots; FH, forehand shots; SR, serves
Monday Wednesday Friday
Week three30 FH25 BH10 BHRest 10 min30 FH25 BH10 SR
30 FH25 BH15 SRRest 10 min30 FH25 BH15 SR
30 FH30 BH15 SRRest 10 min30 FH15 SRRest 10 min30 FH30 BH15 SR
Week four30 FH30 BH10 SRRest 10 minPlay 3 games10 FH10 BH5 SR
30 FH30 BH10 SRRest 10 minPlay 1 set10 FH10 BH5 SR
30 FH30 BH10 SRRest 10 minPlay 1 1/2 sets10 FH10 BH3 SR
INTERVAL TENNIS PROGRAM
4 weeks, 3 days at week
Gradual increase of repetitions
Recovery of gestures
“Data based” Interval Sport Program – Age-specific– Specific for the position– Specific to the level of play– Specific to the type of injury– Specific for the duration
Axe M et al . Sports Health, 2009
Recovery of gestures
Return to play criteriaOur proposal
Ismoetric HHD:• 0-0: ER/IR ratio
>75%• 90-0: ER/IR ratio
90-100%• 90-90: ER/IR ratio
60-85%
• Complete recovery of strenght
At least simmetrical EccIR force• Tested by isokinetic
machine• Or HHD • Or at least simmetrical
endurance during exercises
Cools et al. KSSTA 2015
• Complete recovery of ROM
• <20° side diff for IR
• <10° side diff for Total ROM
• No pain in “forced” passive ROM
Our proposal
• No signs of dyskinesia
Return to play criteria
• No alteration in sport gestures coordination
• Use the McClure metod to evaluated
• Don’t look at simmetryClarsen et al. Br J Sports Med. 2014 Sep
McClure et al. J Athl Train. 2009
• Put attention to shoulder horizontal abduction and trunk angolar velocity
• Use video analysis (www.kinovea.org)
• Complete data-based interval training program
Thank you for attention
• Search for this presentation on www.slideshare.net
• Follow me on Twitter: @AleGiannini82
• For any questions: a.giannini@isokinetic.com
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