Background
Mike is a fit and healthy 31 year old with a strong sporting background. Rugby is his main sport but over the last two years this has been impaired due to recurrent right shoulder pain. In addition to the deep pain in his shoulder joint he had a feeling of not trusting his shoulder and has had instances of instability.
Over the years Mike has had physio, corticosteriod injections and tried different types of rehab programmes. Unfortunately, his symptoms persisted which led him towards meeting an orthopaedic surgeon in May 2020. After a physical examination an MRI was deemed necessary and the main findings are below.
The glenoid labrum is an important part of the shoulder joint. It deepens the socket and provides extra stability as the socket is actually quite shallow in terms of the size of the ball (humeral head). The labrum is highlighted is green below.
The top part of the labrum is most commonly torn as the long head of the biceps tendon attaches to it there. Unfortunately for Mike, there was tearing to nearly all of his labrum. A decision was made to operate and try to repair the labrum. The aim of this would be to increase the stability of the shoulder and decrease pain levels.
Finalising a surgery date was complicated by COVID-19 but Mike underwent his procedure on July 2nd 2020. For anybody interested in the exact procedure the operation notes describe an "Arthroscopic Anterior, Posterior, Superior Labral Repair (360°)". Wilson et al (2018) provide a thorough description of this type of surgery here. Mike's surgery would have been individualised to his presentation and the surgeons preference.
Road to Recovery
As anyone who has had a surgery can attest to the operation is only the first step of recovery. With a shoulder surgery the early stages can be particularly challenging as you are extremely limited in the use of your arm. It is critical to protect the surgical site and allow early healing to take place undisturbed. Mike was meticulous in following his post op precautions. They even got him out of nappy changing duty for a few weeks! The guidelines Mike stuck to are below.
Physiotherapy Input
Mike reported to his first session on July 30th, exactly 4 weeks after his operation. At this point he had been reviewed by his surgeon who was pleased with his early recovery. Mike was still wearing his sling at all times and had not moved his shoulder at all either passively or actively.
I believe the first session is crucial in any episode of healthcare. Building a strong "therapeutic alliance" is extremely important in optimising outcomes. In simple terms, this means getting on with your physio! In this scenario I knew Mike before he needed physio which helped. Despite this, I knew he would have plenty of questions about his recovery and one of my primary jobs was to answer these and put him at ease. Trusting your physio during post op rehabilitation is critical. It is inevitable your physio will ask you to do things you haven't done since the operation and you need to trust in their skillset.
By the end of our first session we had a programme designed and recorded so Mike knew exactly what to do. Starting to spend some time during the day in a controlled environment out of the sling was also encouraged. Some of the exercises from our first session are below. They are quite simple but encourage low level contraction in Mike's shoulder muscles and start to get the joint moving again.
Active Range of Movement (External Rotation, Abduction, Flexion)
Banded Isometric External Rotation
Towel Press Isometric Flexion
Weeks 4-10 Post Op (Early Stage Rehabilitation)
To provide an overview of the rehabilitation process it is helpful to break it down into stages. In total we worked together for 14 appointments over a 23 week period. We have already seen what happened in our first session so let's look at how we progressed over the next 5 weeks.
Mike's post op protocol helped guide our decision making and as you can see below there is clear emphasis on protecting the tissues that were operated on. Doing too much, too soon can create increased inflammatory responses in the tissues and in a worst case scenario there can be structural damage to the repaired tissues or disruption of surgical fixations.
Improving shoulder range of motion, introducing loaded tasks to shoulder muscles in a safe way and beginning to use the arm out of the sling for day to day tasks were prioritised.
By the time we hit the 10 week mark Mike was able to flex his shoulder to 150° and abduct it to 100°. Mike managed 45° of external rotation. This improved significantly from his ability in week 4 where flexion was 45°, abduction was 30° and external rotation was 10°. Although this increase in movement is nice to measure it is equally important to track improvements in how daily tasks are managed. Over this period Mike became more comfortable out of the sling and was managing things like washing his hair, brushing his teeth and picking up lighter objects with his right hand. He was also back in the nappy changing game!
The videos below demonstrate some of the exercises we used during this phase.
Seated Towel Slide ( 45°)
Banded Active Assisted Flexion
Side Lying External Rotation at 0° Abduction
Bent Over Horizontal Abduction at 45° & 90°
Supine (Off Bench) Serratus Slide
By the end of this stage we were able to introduce holds in a push up position and some simple lateral stepping exercises from this position. Including exercises where the arm is free in space like the exercise above and exercises where the hand is fixed to the ground or a wall is important. This allows varied stimulus to be interpreted through the nervous system and helps retrain firing of appropriate muscles in a coordinated pattern.
Week 11 - 17 Post Op (Mid Stage Rehabilitation)
The transition from our early stage to mid stage coincided with Mike spending some time on holidays. This facilitated a period of gaining confidence in progressing the challenge of his exercises without physiotherapy guidance. For the 3 week break between sessions we ensured Mike had a programme with progressions ready to move onto if he felt ready. This typically involved increasing the weight used for an exercise or increasing the range of motion of an exercise. Our timing also lined up well with Mike's post op protocol. By starting to use the arm above shoulder level there is more stress placed on the shoulder capsule and inherently more stress through the surgical sites.
Shoulder range of motion was coming along nicely at this stage and Mike's movement of his right shoulder was quite close to his left. We had focused on restoring natural movement around Mike's shoulder blade as bringing the arm overhead smoothly requires coordinated movement through the glenohumeral joint and scapulothoracic joint. It is very common to see the shoulder hitching up towards the ear but Mike was conscious of this while performing rehab exercises. A mirror was regularly used to provide visual feedback in addition to Mike developing a "feel" for when the shoulder was starting to shrug.
Shoulder Range of Movement (Abduction) Week 12
One addition to Mike's programme at this stage was perturbation style training. This requires quick, responsive muscle contractions due to unpredictable changes in tissue length. The thinking with these types of exercises is that being able to maintain relative joint stability and accurately reposition the limb (joint position sense) during episodes of external forces is an important athletic quality (Burne & Tack 2017). This is what the exercises look like.
Split Squat & Flexion Banded Perturbation
Standing Abduction Banded Perturbation
Putting Mike into more vulnerable positions in a controlled manner was also on the cards at this stage. Good examples of this are controlling weight overhead while the torso moves and supporting the body weight through one arm while the torso moves. This requires interpretation of varied stimulus again and more force needs to be exerted to complete the tasks. An example of both challenges are below.
Dumbbell Windmill (Mike Used a kettlebell at home)
Push Up Position T Rotation
We have already touched on the fact that subjective feedback about progress is very valuable. A nice marker of functional improvement at this stage was that Mike successfully played his part in moving house. He felt confident lifting, carrying, dragging and even doing some DIY which involved drilling overhead!
Mike was also starting to ask about throwing a rugby ball which I took as a very positive sign. Performing tasks that require higher speeds of movement are typically avoided by anyone who is apprehensive about the ability of their shoulder.
With this in mind we introduced exercises where Mike had to generate forces more quickly (wall push up) and coordinate faster movement of the limb in a challenging position (abduction and external rotation).
Explosive Door Push Up With Single Arm Catch
Half Kneeling Throw and Catch (Abduction & External Rotation Position)
As we moved into our late stage rehabilitation we needed to consolidate our programme and make sure it was well documented. By mid November the programme below was the core of our rehabilitation.
Week 18 - Present (Late Stage Rehabilitation)
At this point we used another three week opportunity for Mike to self guide his rehabilitation. The programme above was the core work he did but when we met in December Mike happily reported he got involved in a game of tip rugby with the team he coaches in Cork Constitution. He was comfortable sprinting, passing and changing direction quickly. Thankfully we had been working on maintaining lower limb conditioning while going through our shoulder rehab!
Adding to Mike's programme at this stage saw us considering falling onto the limb and dealing with contact scenarios in rugby. Mike promised he wasn't planning a return to competitive rugby but did want to feel comfortable playing tip and dealing with "awkward" scenarios like falling onto an outstretched limb or having to use the limb to fend people off playing 5 a side soccer. I didn't really believe Mike about not going back to competitive rugby but all will be revealed next season!
We included drills like multidirectional bear crawls, bear crawl to single arm wall hold transitions and tall kneeling to plyometric pushups. Mike tolerated these well and ideally our next step would have been to begin controlled contact scenarios. We also used dynamometry to accurately measure Mike's ability to generate muscle forces. It was very reassuring to see very minimal differences between sides.
Unfortunately, COVID-19 restrictions limited our return to rugby progression. On a more positive note, Mike is fortunate to have a Cork Constitution clubmate (Billy O'Regan) who is a strength and conditioning coach with a special interest in preparing athletes for contact in team sports. I ran through one of Billy's programmes with Mike and it served as an excellent transition to more specific training. A point where Mike outgrew the clinic environment was inevitable and a smooth handover to a suitable strength and conditioning coach is extremely important. I discussed a strategy with Billy to reintroduce tackling drills and contact scenarios in a controlled environment and gradually allowing the environment become more open. Billy was on the same page and will implement this along with his own ideas once it is safe to do so in keeping with COVID-19 guidelines.
Summary
Looking back at this case it is important to reflect on the timeframes involved. Mike was 6 months post op until he felt confident he no longer needed physiotherapy. That is quite a long road and challenges for the patient and physiotherapist are inevitable. Key factors that contributed to a good outcome in this case were an excellent surgical intervention, Mike's adherence to early precautions and a good understanding from both of us that consistent, progressive rehabilitation over a period of months was the main priority. We did use hands on techniques during Mike's recovery and they certainly played their part. However, if we look at Mike's typical rehab week there may have been a maximum of 10 - 15 minutes of manual therapy but over 3 hours of exercise if Mike did a 30 - 40 minute session on 6 days of the week. I know what I would be prioritising if I was a patient!
There were times when progress seemed slow but stepping back and looking at overall improvement is useful in these scenarios. Open discussion and listening to any concerns is essential to maintaining a good working relationship. We certainly had sessions where a good chunk of our time was spent discussing a certain aspect of the programming or planning how best to bridge a gap without an appointment, over Christmas for example.
Mike's attention to detail and discipline in following the programmes made my job much easier and seeing Mike happy with the outcome was hugely rewarding. I am looking forward to hearing if he keeps his word about going back to rugby or not!
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As a physiotherapist who has worked in hospital settings for over 5 years I have helped people recover from a wide range of operations. These span from shoulder surgeries for athletic populations like Mike to total knee or hip replacements for people who had advanced osteoarthritis. If you think you may need help after an operation or if you know somebody due to have an operation I would be delighted to speak with them!
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References
Burne & Tack (2017) "Overhead Perturbation Training" Strength and Conditioning Journal (39) 3: Link
Ferreira et al (2013) "The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain" Physical Therapy (93) 4: Link
Wilson et al (2018) "Arthroscopic 360° Shoulder Labral Reconstruction: A Stepwise Approach" Arthroscopy Techniques (7) 9: Link
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