Intervention for Rotator Cuff Repair with Subacromial Bursectomy: A Case Study
Sydney Bethards, SPTA
Indian Hills Community College
Physical Therapist Assistant Program
PTA 281: Seminar for PTA
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Abstract
Background and Purpose:
Case Description: A 48-year-old male tractor trailer driver status post right rotator cuff repair after sustaining a high-grade partial thickness tear from performing a repetitive motion of turning cranks on a semi. Physical therapy interventions included range of motion, strengthening, and relaxation exercises.
Outcome:
Conclusion:
Background
The four muscles of the rotator cuff surround the humeral head anteriorly, superiorly, and posteriorly that actively hold it against the glenoid fossa. These four muscles consist of: subscapularis, infraspinatus, teres minor, and supraspinatus. The greater tubercle of the humerus is the insertion point to the teres minor, supraspinatus, and infraspinatus, whereas the lesser tubercle is the insertion point subscapularis. Both the infraspinatus and teres minor controls external rotation movement by the shoulder. The supraspinatus performs shoulder abduction and the subscapularis performs shoulder internal rotation.1
The rotator cuff is the primary and dynamic stabilizer to the loose-fitting glenohumeral joint as the shoulder performs motions in multiple planes. These motions include: adduction, abduction, flexion, extension, external and internal rotation, horizontal abduction and adduction. The glenohumeral joint is also supported by capsular ligaments, the coracohumeral ligament, the long head of the biceps, and the glenoid labrum. The ligaments and the capsule of the glenohumeral joint are quite thin and provide only secondary stability to the joint.1
During shoulder abduction and flexion, there is a natural 2:1 ratio between the scapula and shoulder joint. This means that for every 2 degrees of shoulder abduction or flexion, the scapula performs upward rotation of 1 degree.1 Therefore, scapular stabilization and strengthening is provided in a shoulder protocol.
A rotator cuff tear usually happens over time from normal wear and tear or from repetitive motion involving the arm, in particular, the shoulder joint. Age can also be a factor in developing a rotator cuff tear, meaning individuals who are 60 years of age or older will be more likely to develop a tear. Although, it can also happen should the individual fall or lift something heavy, straining the joint and the muscles. The two types of tears in the rotator cuff are partial or complete. A partial tear involves the tendon being frayed or damaged, whereas, a complete tear involves the tendon being pulled off the bone.2
An individual may not always feel a tear in the rotator cuff. Common symptoms of a rotator cuff tear include: (1) having trouble raising the arm, (2) pain with certain movements of the arm or after lying on the arm, i.e. while sleeping, (3) weakness in the shoulder, (4) inability to lift things that are usually lifted with ease, or (5) hearing clicking or popping with any movement of the arm.2 If these issues are ignored, an individual could obtain frozen shoulder or arthritis. Although the cause of frozen shoulder is idiopathic, periods of pain and/or restricted motion can potentially lead to frozen shoulder, and arthritis can occur from microtrauma to the shoulder due to overuse.4 If these symptoms are overlooked for a long period of time, the risk for these pathologies can increase.
To diagnose a rotator cuff tear, a doctor will start by obtaining the history of the shoulder and perform a physical examination of the shoulder. The physical examination includes range of motion measurements and strength testing. He or she will also exam which motions generate the most pain and where the pain is located. The doctor may also use a form of imaging including Magnetic Resonance Imaging (MRI), X-rays, or even diagnostic ultrasound. An MRI is the most common mechanism used to identify a tear in the rotator cuff. X-rays are used to see the top of the humeral head to observe if it is pushing into the rotator cuff space. Diagnostic ultrasound is used to see the soft tissues such as the tendons, muscles, and the bursae in the shoulder.2
During an MRI, pictures are taken of the shoulder to observe the site of the tear. MRIs are used to detect tissue damage, infection, tumors, arthritis, torn tendons, worn-out cartilage, or tears in the labrum of the shoulder. Contrast material, a chemical substance that is distributed through the veins or injected directly into the shoulder joint to improve the quality of the pictures, may be used to check blood flow or show areas of inflammation or infection within the ligaments, muscles, cartilage, and other joint structures in the shoulder. With X-rays, ultrasound, or a CT-scan, the structures are not as clear compared to an MRI. However, these tests can detect impingement of the shoulder.3
Tests performed by a physical therapist for rotator cuff pathology include: (1) cross-over impingement, (2) drop arm test, (3) empty can test, (4) Gerber’s test, (5) lift-off test, and (6) posterior impingement test.5 For a detailed description of each of these tests, see Appendix B.
Conservative treatment after being diagnosed with a rotator cuff tear may include a combination of physical therapy to make the shoulder muscles stronger, increase the range of motion in the shoulder, and decrease the pain that the patient is experiencing. Medications such as acetaminophen and anti-inflammatory drugs may be used to decrease the pain and inflammation in the shoulder. The Physical Therapist may also give the individual a home exercise program to help with pain management and range of motion.2
If conservative management doesn’t resolve the problem, surgery may be needed, especially if the individual has a complete tear in the rotator cuff. The three types of rotator cuff surgeries include open, arthroscopic, and mini-open. Open type is the use of larger instruments fixing a tear in the muscles of the shoulder. Arthroscopic type is the use of an arthroscope inserted through a small incision in the shoulder to repair the tear. With this procedure recovery time is minimal. As arthroscopic assisted repairs have advanced, the use of the traditional open approach has decreased. Mini-open type uses methods from both the arthroscopic and open procedures. The surgeon starts with the arthroscope then ends with the larger surgical instruments. There are two different types of mini-open procedures both including subacromial decompression and a deltoid-splitting approach. In both, an anterolateral incision is made at the acromion and is extended distally along the fibers of the deltoid insertion. Then the deltoid is spilt in two so the surgeon can view the tear without detaching the deltoid from its origin.2, 4
Immobilization and position of the shoulder with a sling is dependent upon the type and quality of repair, as well as location, size, and severity of the tear. Generally, a specific protocol is followed by physical therapists for individuals who receive rotator cuff tear surgery. This includes early shoulder motion such as relaxation techniques and scapular exercises for the first 6 weeks after surgery; once the sling is off, assisted range of motion may be performed as tolerated for 7 to 12 weeks, then strengthening is added at 13 weeks.4
The recovery process primarily depends on the size of the tear and how long the rotator cuff was torn. The smaller and more recent the tear, the better the chances of becoming pain-free and having a full range of motion at a faster rate. The recovery process of a rotator cuff repair could take up to a year. Patience is the key to success with this diagnosis.2
Case Description
Patient
This patient is a 48-year-old man (Brad), who drives a tractor trailer for a living and lives with his wife and two sons. His past medical history includes: diabetes, hypertension, hyperlipidemia, sleep apnea, and gastroesophageal reflux disease (GERD). Brad states that he previously broke his collar bone, had a herniated disk, and his right knee has been broken in three places and it is still not completely fixed. He also uses smokeless tobacco daily in the form of a pouch; stating that he uses one pouch per day. Brad mentions that he does not currently consume alcohol. His current medications include: 220 mg of Aleve and 200 mg of Ibuprofen taken by mouth as needed with a limit of 3 tablets per day, 10 mg of Baclofen by mouth as needed, 500 mg of Metformin, 20 mg of Simvastatin, and 2.5 mg of Lisinopril taken daily by mouth. On December 3, 2017, he experienced significant pain in his right shoulder after performing a repetitive motion of rotating a crank. Brad explains that he was performing a motion involving the elbow being flexed and the shoulder performing shoulder flexion and extension. He mentions that his shoulder has been “catching” for almost 2 years. This patient is right handed. Brad went to the doctor for right shoulder pain. The doctor obtained the history of the patient’s shoulder including: a dirt bike injury in his 20s and on and off pain up until this injury. He states that he is unable to lift a glass of water at this time and has increased pain with any effort to lift his arm above 90 degrees in all planes. He had decreased range of motion and normal strength.
During the physical examination with the doctor, the Hawkins and Neer tests were performed and were both painful to the patient; shoulder pain with these tests indicate shoulder impingement particularly of the supraspinatus tendon. The doctor noted that there was mild tenderness in the bicep and the acromioclavicular joint showed mild to moderate tenderness. Brad had some discomfort with cross body adduction as well. Brad had an X-ray of the right shoulder including anterior and posterior views, and views of the scapula. The X-rays showed degenerative changes of the acromioclavicular joint.
Brad had an MRI performed on December 28, 2017. The patient was injected with iodinated contrast by needle into the anterior glenohumeral joint space. The imaging indicated that he had a complex tear of the supraspinatus tendon with a grading of partial and extension to the far anterior infraspinatus tendon and an os acromiale measuring 2.5 x 1.8 cm. The teres minor, subscapularis, and the biceps were still intact. The tear of the supraspinatus tendon measured 21 mm in longitudinal dimension. The MRI also revealed that medial intrasubstance delamination is present at the posterior supraspinatus and far anterior infraspinatus tendons. There was a small amount of fluid within the subacromial space and subdeltoid bursa. No labral tear or cartilage defect was detected by the MRI. Lastly, there was mild acromioclavicular joint osteoarthritis present.
Brad was very disappointed to realize he needed to have surgery and wouldn’t be able to work for at least 13 weeks. He is the sole provider of his family and stated that he needed to work to support them. Brad has been following his protocol and being very compliant with the program; he is determined to get back to work and considered a position at his job that offers less strenuous activity, and doesn’t involve motions and requirements that would be damaging to his progress, at least until he can go back to his previous job.
Surgery
On January 22, 2018, the rotator cuff repair was performed under general anesthesia. The procedure consisted of the arthroscopic type of repair. Three incisions were made around the shoulder joint so that the arthroscope could be inserted into the shoulder. Small surgical instruments were inserted in the remaining incisions. Three-fourths of the tendon appeared to be ripped in two pieces and minor tears were present. Two anchors were inserted and placed near the acromioclavicular joint and sutures were placed along half of the supraspinatus tendon, superior of the acromioclavicular joint. The doctor also cleaned the arthritis out of the joint and removed the bursa.
Initial Evaluation
The initial evaluation was performed on February 9, 2018. During the initial evaluation, the patient stated that his shoulder felt good but was sore. He also mentioned that he has been performing his exercises at home. The patient complains of constant throbbing pain that shoots down his arm. He rated his pain at the initial evaluation at 7 to 9 out of 10. The pain radiates no further than proximal 2/3 of the right upper extremity. He states that it is very uncomfortable to sleep due to the sling. At the time of the evaluation, he was taking 50 mg tablets of tramadol as a pain reliever as needed. He was instructed to use his sling at all times except while bathing for 6 weeks after surgery. He is partially compliant with this order; he stated that sometimes he does not wear it when he sits at home. The incision sites showed normal healing and they were noted to be clean. The patient’s main goal is to return to work.
Range of motion
The patient’s range of motion was tested passively. Flexion was 75 degrees with significant increase in discomfort. Abduction was 70 degrees, external rotation was 0 degrees, and internal rotation was also 0 degrees. His range of motion was significantly decreased compared to normal range of motion.
Plan of Care
Brad’s plan of care consists of a duration of 10 weeks at 3 times per week. A home exercise program was prescribed consisting of exercises listed for the first 6 weeks per protocol, see Appendix A for further details. Modalities including IFC electrical stimulation and a moist hot pack will be used for pain management as needed, and supervised exercises during treatment will also be based on the protocol. Treatment procedures and progression were developed based on the protocol provided by the doctor as well (see Appendix A). The patient was instructed not to actively move his right shoulder at this time.
Goals
1. Verbal pain rating should be decreased from 7 to 9 out of 10, to 0 out of 10 in 4 weeks.
2. The patient will be 100% proficient with home exercise program in 4 weeks.
3. Range of motion should be increased in 6 weeks:
a. Flexion to full range at 180 degrees
b. Abduction to full range at 180 degrees
c. External rotation to full range at 90 degrees
d. Internal rotation to full range at 70 degrees
4. The patient will regain full function of the right shoulder in 12 weeks.
Outcome Measures
The outcome measures for this patient will consist primarily of range of motion measurements with a standard goniometer. A pain rating scale that is recorded verbally ranging from 0 to 10 will also be used with this patient to show improvement. In the pain scale, 0 referred to as no pain at all and 10 was referred to as pain in which you would need to go to the emergency room at the hospital. Due to therapy being based on a protocol, the patient had to progress according to his doctor’s orders. Manual muscle testing (MMT) will be added when strengthening is allowed with the protocol; roughly 13 weeks post operation.
Treatments and Interventions
The protocol that Brad is required to follow includes six separate levels. The first level (weeks 3-6 postoperative) consists of pendulums, assisted range of motion of the elbow, active range of motion of the wrist and hand, theraputty, scapular retraction and shoulder shrugs, passive range of motion of the shoulder, and modalities for pain and swelling. The second level (weeks 7-12) includes prone scapular stabilization, pulleys, wand exercises, table slides with a towel, wall slides only to 120 degrees of flexion, side-lying external rotation, thoracic spine extension, horizontal flexion stretching, and PNF diagonal active range of motion in supine. The third level (weeks 13+) is the start of strengthening of the shoulder. During this level, theraband, free weights, wall push-ups, and manual resistance are added. The fourth, fifth, and sixth levels are advanced exercises that are more intensive and include core strengthening, see Appendix A for further details.
For a rotator cuff repair, most commonly a protocol is used. The patient is generally in a sling for 6 weeks due to a medium to large tear (1-5 cm). During the maximum protection phase, the main goals are: controlling pain and inflammation with the use of modalities, preventing loss of mobility in other structures including the wrist and elbow by performing assisted range of motion of the elbow and active range of motion of the wrist, preventing shoulder stiffness and restoring shoulder mobility with pendulums and passive range of motion of the shoulder, preventing or correcting postural deviations with use of shoulder shrugs, and developing control of scapulothoracic stabilizers with exercises such as scapular retraction and protraction. During the moderate protection phase, restoring complete or full, pain-free, passive mobility of the shoulder, increasing strength and endurance, and re-establishing dynamic stability of the shoulder are the most important goals. By utilizing pulleys, diagonal patterns, and wand exercises, the range of motion should be restored to a nearly full and pain-free motion. To increase strength and endurance and re-establish dynamic stability, isometric exercises and exercises with the use of resistance including theraband and free weights can be used. During the minimum protection/return to function phase, goals and interventions are based on the moderate phase. Although if full range of motion has not been restored, passive stretching of the glenohumeral joint and joint mobilizations may be used. Patients are usually not allowed to return to high-demand activities for 6 months up to a year postoperative, depending on the patient’s strength, flexibility, and level of comfort.4
At Brad’s first visit on February 9th, passive range of motion measurements of the shoulder were performed. Passive range of motion measurements included flexion of 75 degrees, abduction of 70 degrees, and internal and external rotation of 0 degrees. The patient was limited to passive range of motion and to 90 degrees as per protocol.
The first week of therapy, the patient started exercises based on the first level of the protocol. These exercises include: wrist and hand active range of motion with theraputty for 5 minutes, scapular retraction, forward and backward shoulder shrugs, active elbow extension, pendulums, and table stretches with a towel for 3 minutes each. Passive range of motion is performed to the patient’s shoulder for 3 minutes after he performed the exercises. At the end of treatment, IFC electrical stimulation and a cervical moist hot pack is applied to the right shoulder for pain relief. During the delivery of electrical stimulation, the patient is seated and a pillow is placed under the patient’s arm for comfort. On Brad’s 8th visit, deep tissue massage to the upper trapezius and shoulder was added to decrease pain.
These exercises continued until Brad’s sling was discharged at 6 weeks then on the 7th week postoperative, assisted range of motion exercises were added to his treatment. At week 7 per protocol, full range of motion is performed as tolerated. The exercises that were added include: pulleys with flexion for 5 minutes, finger ladder to 120 degrees of flexion, flexion, extension, and abduction with the wand, thoracic extension, and side-lying external rotation for 3 minutes each. Scapular retraction, shoulder shrugs, and table slides with a towel are still utilized in Brad’s treatment. On March 14th, Brad was only able to perform side-lying external rotation for 2 minutes due to increased pain. Brad was told to stop the exercise and at his next scheduled treatment, assisted range of motion of external rotation was performed with his arm bent on a table raised to 90 degrees of abduction instead of side-lying external rotation. Brad was instructed to lean forward in order to facilitate the motion of external rotation. On Brad’s 17th visit, abduction was added while performing pulleys.
Outcomes
Brad progressed with the use of physical therapy. The outcome measures that are primary for this patient include passive range of motion measurements and pain level. Brad’s passive range of motion measurements for shoulder flexion and abduction were taken on February 26th, 2018. These measurements were 120 degrees of flexion and 110 degrees of abduction; as per protocol 4 to 6 weeks postoperative no more than 120 degrees is allowed. Once the restricted range of motion limit was lifted on March 12th measurements were taken again; his passive motion was 145 degrees of flexion and 91 degrees of abduction due to increased pain. On March 19th, his passive measurements were 146 degrees of flexion, 88 degrees of abduction due to pain, 60 degrees of internal rotation, and 28 degrees of external rotation. The next visit his shoulder flexion and abduction were reassessed. After adding pulleys with abduction to the treatment, his passive flexion was 152 degrees and his passive abduction was 141 degrees with no pain.
Brad’s pain was very discontinuous throughout treatment. Although, pain is essentially decreased from the initial evaluation. At the initial evaluation, Brad rated his pain at the most severe level of 7-9 out of 10. On February 28th Brad was asked to rate his pain at the beginning of treatment. His response was 5-6 out of 10 and he mentioned that he had taken his tramadol before coming to therapy. Brad was asked again on March 5th and he responded that his pain was 1-2 out of 10 without his pain medication. He also mentioned that he had bought a TENS unit and has been using it for 20 minutes, three times a day. Brad rated his pain on March 14th a 5-6 out of 10. The patient states that he was very sore after the new exercises were added. On March 19th, Brad rated his pain 6-7 out of 10 and complained of pain in his left wrist. March 23rd his pain significantly decreased to 3-4 out of 10.
References:
1. Mansfield PJ, Nuemann DA. Essentials of Kinesiology. St Louis, MO: Elsevier Mosby; 2014.
2. What Is a Rotator Cuff Tear? WebMD. https://www.webmd.com/fitness-exercise/guide/rotator-cuff-tear#1-2. Accessed March 11, 2018.
3. Magnetic Resonance Imaging (MRI) of the Shoulder. WebMD. https://www.webmd.com/a-to-z-guides/magnetic-resonance-imaging-mri-of-the-shoulder. Accessed March 12, 2018.
4. Kisner C, Colby LA, Borstad J. Therapeutic exercise: foundations and techniques. 6th ed. Philadelphia: F.A. Davis Company; 2018.
5. Konin JG, Lebsack D, Valier AS, Isear JA. Special tests for orthopedic examination. 4th ed. Thorofare, NJ: SLACK Incorporated; 2016.
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