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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Tag: shoulder rehab

As I write this update, I have now been back to work for a month. The first 3 days back were challenging, as I had not done that much with my arm in quite some time. I was sore by 5 pm each day, but no significant pain. The soreness resolved by the next morning. I quickly realized how weak I was as I attempted to stretch a client’s hamstring lifting the right leg up with my left arm.

With that said, going back to work also facilitated me moving the arm more frequently and using it against gravity. This has allowed me to regain more functional mobility and strength the past month. I have been careful to avoid any heavy or overhead lifting. I have not encountered something I could not do yet in patient care, but I have had to be aware of my body mechanics and positioning to reduce strain on the left arm.

MD follow-up

I saw the doctor this past Friday. He was pleased with my progress and encouraged me to keep working on regaining the last portion of my ROM. I will go back for one final appointment in 6 weeks. Of note, I had previously asked him to image the right shoulder to see if I had a tear since I have been having some right shoulder pain that has worsened since the left shoulder surgery. The MRI revealed a partial tear (30-40% of mostly bursal-sided fibers), some degeneration in the anterior labrum, biceps inflammation and a sizable bone spur. In essence, the doctor says I need to have the bone spur taken out in the near future to avoid a full tear on my right side. Not great news, but I am relieved it was not fully torn.

Rehab and Exercise

I am continuing to get stretched 2x/week, while doing my pulley and ROM exercises daily at home. I am performing scapular and rotator cuff strengthening about 3x/week. I returned to the gym for the first time on Labor Day. This was a humbling day to be sure as I cannot even do 50% of my previous weight with pull downs, rows and other lifts. But, Rome was not built in a day, and I know it will likely take up to a year to get back to 100% again.


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Well, I just saw my surgeon as I approach the 11 week post-op mark. I have made good progress since the steroid injection. Although I am still a little stiffer than we both would like, my ROM is progressing and my pain is gone aside from when I or my therapist really stretch it into end range.

Activities of daily living

I am now doing most things (bathing, dressing, grooming, etc.) using my left arm. It was a big deal when I could use my left arm in the drive through and ATM again lol. We tend to take the little things for granted until we cannot do them. I can turn the steering wheel with my left arm, although I will admit it is still a little challenging and fatiguing. Carrying light groceries is no sweat, and I have even started mowing my lawn with a self propelled lawn mower. Keep in mind my yard is flat and relatively small, so I would probably advise most patients to wait a bit longer on that.

Rehab recap

The past two weeks I have continued focusing on AROM and PROM while slowly progressing my strengthening exercises. My typical rehab session looks something like this:

  • Heat x 10 min
  • Active assistive cane ROM exercises x 20 each
  • Pulley: 2 x 15
  • Wall slides x 20
  • UBE x 6 min
  • PROM by PT for 20-30 min
  • Serratus punches – 2 x 10
  • Theraband rows and pulls – 2 x 10-15
  • Theraband internal rotation – 2 xx 10
  • Theraband external rotation walk outs – 2 x 10
  • Side-lying external rotation (no weight) – 2 x 10
  • Stabilization on the wall with a ball (up/down, side-to-side, circles) 2 x 10
  • Prone extension (light weight) – 2 x 10
  • Prone horizontal abduction (no weight) – 2 x 10
  • Standing flexion and scaption (0-1#) 2 x 10 focusing on no shrug in my range of motion
  • Ice x 10 min

The entire session takes about 90 minutes. Of course, I am navigating all the exercises on my own and relying on a colleague to do the PROM. With respect to the strengthening, my focus is on form, time under tension, avoiding excessive upper trap and compensatory motion, and ensuring I am not experiencing pain as I move the arm.


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In the case of shoulder pain and dysfunction, the lower trapezius and serrates anterior are often implicated as part of the problem. Research has shown that these two muscles often fatigue and don’t contribute equally to the force couple between them and the upper trapezius that facilitates upward rotation of the scapula.

Building scapular stabilization and dynamic stability is a must for those doing repetitive overhead activities such as throwing, swimming, serving, or work-related tasks.  It is a given that asymmetries will exist, so optimizing the strength of the rotator cuff and scapular stabilizers is paramount to prevent injury and recover from overuse syndromes.

To strengthen the lower trapezius, one of my ‘go to’ exercises is the lower trap raise. It can be done with just the weight of your arms or using light dumbbells.  The link below includes the full description for the exercise, and I also embedded the video below.

http://fit-pro.com/article-4137-Lower-trap-raise.html

In the next column, I will include a serratus anterior exercise using a kettle bell as a follow-up to this post.

SLAP tears are a common problem for overhead athletes among others today. There is no consensus per se in how to treat them and results following primary repair are mixed. Common complaints following a repair are persistent pain and stiffness. In the past, I have writtne about SLAP tears as well as outcomes for elite pitchers.

type2slap

In addition, I have discussed outcomes for type 2 SLAP tear revision surgery on this blog.  What always concerns me (and more importantly patients who undergo surgery is how to achieve predictable pain relief and recover shoulder function.  In the April 2014 edition of the American Journal of Sports Medicine, there is a level 4 prospective study by McCormick et al. looking at the efficacy of subpectoral biceps tenodesis as a viable solution for failed primary SLAP repairs.  The study took place from 2006-2010 and all procedures were performed by 2 fellowship trained surgeons at a tertiary military facility.

Subjects: Active-duty men and women b/w 18 and 50 years old who had arthroscopically confirmed type 2 SLAP lesions and who then underwent arthroscopic repair and were subsequently unable to return to duty(follow-up period was 2-6 yeaers with mean follow-up of 3.5 years).  They also had to consent to a biceps tenodesis to address the failed repair.  All told, 42 of 46 patients completed the study.  The mean age was 39.2, while 85% of the subjects were male.

Criteria to be included in the study: inability to return to active duty within a minimum 6 months of surgery, ASES score less than 75 at 1 year follow-up from the primary procedure, or patient electing to undergo revision surgery due to dissatisfaction with the primary results.

Procedure: Biceps tendon was released and the remaining stump was debrided so the superior labrum was confluent with the remaining labral tissue.  All sutures and loose anchors were removed.  If the rotator cuff interval was inflamed, debridement with a 4.o mm shaver was used and/or radiofrequency wand was used.  Next, a 2 cm incision was made in the axillary skin crease at the inferior border of the pec major.  The biceps tendon was anchored 1 cm proximal to the musculotendinous junction using a nonabsorbable suture and 8 x 12 interference anchor fixation.

Rehab protocol: Patients were in a sling for 4 weeks with no active biceps use for 6 weeks.  They all underwent graded supervised physical therapy consisting of an initial 6-week phase of passive ROM exercise in addition to scapular and core strengthening. This was followed by progressive strengthening at 6 weeks and return to-duty-evaluation at 3 months post-op.

Results

  • 34 patients (81%) returned to active duty
  • Clinically significant improvement across all outcome measures after revision surgery as follows:
  1. Pre-op ASES = 68 and post-op ASES = 89
  2. Pre-op SANE = 64 and post-op SANE = 84
  3. Pre-op WOSI = 65 and post-op WOSI = 81
  4. Pre-op shoulder flexion = 135 and post-op shoulder flexion = 155
  5. Pre-op shoulder abduction = 125 and post-op shoulder abduction = 155

Summary

Currently, there is no standard of care for failed SLAP repairs.  One previous case control study by Boileau et al. found higher satisfaction in those undergoing biceps tenodesis compared to arthroscopic repair in the management of an isolated SLAP tear. Further, in the Boileau study there were no failed tenodesis procedures and those opting for that as revision had a full return to previous sports activity.  This prospective study by McCormick et al. resulted in similarly high rates of return to previous activity and clinically significant improvements in outcome scores and ROM.

There are several reasons why primary SLAP repairs may fail including: postoperative stiffness as a result inadvertent restriction of physiological biceps excursion or nonanatomic biceps anchor reduction, suture anchor pullout, suture granuloma formation, suture pullout, synovitis, glenoid osteochondrolysis from prominent hardware, a suprascapular nerve injury (due to prominent mendial hardware placement), and a delaminated long head of the biceps.

It is also important to keep in mind the anterior-superior labrum and glenoid are poorly vascularized, and this is thought to limit the healing process.  Persistent pain may manifest after surgery in light of the fact the proximal intra-articular portion of the long head of biceps tendon contains sensory and sympathetic fibers associated with shoulder pain.  The authors’ findings at the revision procedure in this study suggest a consistent constellation of multifactorial complicating factors including: synovitis of the rotator cuff interval, loose knots, and a lack of healing at the glenoid interface.

Key takeaways

  • Outcomes following primary SLAP repairs are inconsistent and patients often continue to c/o persistent pain and stiffness
  • Military personnel (an extremely active population) had excellent results with a tenodesis procedure
  • The results of this study cannot be generalized to the general public nor overhead athletes per se
  • This study did not employ randomization nor did it compare the tenodesis to another procedure/modality so further research should be done on this
  • Biceps tenodesis seems to provide a safe and effective treatment option for failed SLAP repairs at a  minimum of a 2 year follow-up in active individuals

References

Boileua et al. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med. 2009;37(5):929-936.

McCormick et al. The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs. Am J Sports Med. 2014;(42):820-825.

The shoulder mobility screen in the FMS often reveals side-to-side asymmetries.  It is more common to see hypermobility in female clientele, while their male counterparts exhibit more hypomobility.  Overhead athletes tend to demonstrate excessive horizontal external rotation and a relative loss of internal rotation on the dominant side.  This hypomobility can be detrimental to overhead athletes and increase risk for overuse injuries if it becomes excessive.

The following exercise is an effective way to improve shoulder mobility and optimize function.  One important point is to focus on form and move very deliberately through the motion.

Execution: Begin lying on the floor face up.  Bend the left knee up to 90 degrees and cross the right leg over top of the left interlocking them.  Roll to the left side and pin a folded towel or pad between the right knee and the floor.  Place the arms in 90 degrees of shoulder flexion with the right on top of the left in an outstretched position. Next, slowly sweep the right arm up overhead and around the body as you attempt to place the torso/back on the floor.  The finish position for the right arm will be reaching the right hand and arm up behind the back.

Exhale as you perform the sweeping motion and hold the end position for 2 seconds.  Reverse direction and return to the start position.  Perform 5-10 repetitions on each side.

Application: Limited shoulder mobility is a common finding, especially among male clientele with tightness in the pecs, lats and posterior shoulder.  Asymmetry with respect to mobility is common with greater difficulty found trying to reach the dominant arm up behind the back on the FMS shoulder mobility screen.  This exercise will help improve thoracic spine motion and shoulder mobility.  The focus should be on strict form and proper stabilization to avoid unwanted motion.  Pinning the pad (or towel roll) to the floor will help ensure better stabilization.

If hypomibility is an issue and clients score a 1, foam rolling the pec minor/major, latissimus dorsi and the posterior rotator cuff musculature prior to performing the exercise will be helpful.  Stability training can be added in later once the soft tissue mobility restrictions and movement pattern is improving.