search for




 

Physical Therapy Following Arthroscopic Rotator Cuff Repair with Graft Augmentation: A Case Report with Magnetic Resonance Imaging
Phys Ther Rehabil Sci 2021;10:463-9
Published online December 30, 2021
© 2021 Korean Academy of Physical Therapy Rehabilitation Science.

Hyun-Joong Kima and Seungwon Leeb,c

aDepartment of Physical Therapy, Graduate School of Sahmyook University, Seoul, Republic of Korea
bDepartment of Physical Therapy, College of Health Science and Social Welfare, Sahmyook University, Seoul, Republic of Korea
cInstitute of SMART Rehabilitation, Sahmyook University, Seoul, Republic of Korea
Correspondence to: Seungwon Lee (ORCID https://orcid.org/0000-0002-0413-0510)
Department of Physical Therapy, College of Health Science and Social Welfare, Sahmyook University 815 Hwarang-ro, Nowon-gu, Seoul 01795, Republic of Korea
Tel: +82-2-3399-1630 Fax: +82-2-3399-1639 E-mail: swlee@syu.ac.kr
Received December 9, 2021; Revised December 20, 2021; Accepted December 24, 2021.
cc This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objective: If non-surgical treatment fails, arthroscopic rotator cuff repair (ARCR) is recommended, and ARCR considers graft augmentation in consideration of size, direction, and re-tear. It is reported to have potential benefits by improving the healing rate as it can fill the gaps that have been left behind. The purpose of this study is to investigate the effect of structural changes observed after ARCR on muscle action through magnetic resonance imaging and to investigate the effect of appropriate physical therapy required for graft augmentation in the general ARCR rehabilitation protocol.
Case presentation: A 47-year-old male hospitalized for postoperative rehabilitation following ARCR participated in a 5-week physical therapy intervention. The postoperative day was 6 months, but due to shooting pain and shoulder dysfunction,and the movement of the shoulder was compensatory motion, not normal motion. Physical agents, manual therapy, and supervised exercise for 110 minutes per session were performed 3 times a week, and pain intensity, range of motion, function, and strength were evaluated.
Results: As a result of the study, the patient showed positive improvement in pain intensity, range of motion, function, and strength. In addition, normal scapulohumeral rhythm movement was observed.
Conclusions: According to the results of this case, appropriate physical therapy according to the compensatory motion shown in the structural changes after ARCR can positively improve the pain intensity, range of motion, function, and strength of ARCR patients.
Keywords : Postoperative care, Arthroscopy, Rotator cuff injuries, Physical therapy
Introduction

A typical rotator cuff injury in shoulder pain is reported to affect more than 40% of adults over 60 years of age[1]. Also, more than 60% of adults over 70 years of age showed abnormal findings on magnetic resonance imaging (MRI) of the rotator cuff[2]. In a systematic review of the guidelines for rotator cuff repair, it was reported that non-surgical treatment (physical therapy and non-steroidal anti-inflammatory drugs) is more effective when the duration of symptoms in rotator cuff tear is 3 months to less than 1 year[3].

However, if non-surgical treatment fails, arthroscopic rotator cuff repair (ARCR) is recommended, and the number of rotator cuff repairs estimated in the United States is estimated at more than 200,000 each year[4]. Additionally, graft augmentation is considered in ARCR considering the size, direction, and re-tear, and it is reported that there is a potential benefit by improving the healing rate as it can fill the gap lost in the bone attachment of the tendon[5].

In case of ARCR-induced damage to surrounding tissues and joint immobilization, the recovery period is longer when graft augmentation is added[5]. The functional impairment of the muscle associated with a torn tendon reduces the likelihood of generating normal force after repair, mainly due to atrophy and fat infiltration [6]. In this process, chronic fibrosis increases muscle stiffness, which increases the tension in the ARCR region and interferes with the recovery process[7]. In response to the compensatory motion in the surrounding muscles, the muscles continue to tense and enlarge[8].

Therefore, in this study, through a single case of ARCR patient who additionally had graft augmentation, we would like to emphasize not only general problems after surgery, but also structural problems that appear in MRI images after augmentation, and physical therapy rehabilitation according to functional status.

Methods

Ethical standards according to the Declaration of Helsinki were complied with after obtaining informed consent from the patients who participated in this study before the start of the study. This study is a prospective case report, and the procedure is shown in Figure 1.

Patient history and systems review

The patient is a 47-year-old male, a manual laborer working at a construction site. He is 171cm and 72kg, and what stands out in screening is his rounded shoulder posture. He first complained of right shoulder pain in August 2020, endured for about 4 months, and then underwent ARCR with graft augmentation (supraspinatus repair using bilayer engineered skin replacement product, biceps tenodesis, subacromial decompression) at an orthopedic surgeon on December 14, 2020.

Sufficient non-surgical treatment was not performed before surgery. During the period of tolerating the pain, the pain increased further, so when the orthopedic hospital revisited, only an 1.5-T MRI unit (SIGNATM Creator, GE Healthcare, USA) was performed, excluding the physical examination, and then surgery was performed. According to the recorded medical information at the hospital where he was rehabilitated after ARCR, the passive range of motion (ROM) in forward flexion was 180°, but it was actually 130°. Also, it was 87° in active ROM, and he said that he felt a shooting pain.

Examination

When visiting the rehabilitation clinic on June 15, 2021 (around 6 months after ARCR), the patient's consent was given to view the test results before and after surgery. The MRI scan before (December 1, 2020) and after surgery (December 21, 2020) is shown in Figure 2.

The patient's pain intensity was measured using the numeric pain rating scale (NPRS). Usual pain and worst pain were measured from 0 points (no pain) to 10 points (the most severe pain)[9]. For the activeROM of the shoulder, forward flexion, scaption flexion, abduction, internal rotation, and external rotation were measured using a goniometer[10]. For the shoulder function, a simple shoulder test (SST) was used. It is evaluated as “yes” or “no” with 12 items related to daily life, and the higher the score, the lower the function[11]. Muscle strength was evaluated by grip strength and was measured using a dynamometer(TKK-5401, Japan)[12]. It has an adjustable handle and was measured with the patient sitting and with the elbow fully extended.

Clinical impression

This patient appeared to be a good candidate for participation in this study for several reasons. In general, unlike ARCR patients who do not undergo augmentation, shoulder pain and function were not good. Considering the postoperative period, it was thought that there would be chronic fat infiltration and lack of neuromuscular control as a consolidation phase after 6 months in the tendon healing process[13]. In addition, compensatory motion, not normal motion, was remarkably clear, and rather severe pain was accompanied after ROM exercise. Based on these results, it is judged that normal movement was difficult because the muscle vector was changed in MRI after ARCR (Figure 3)[14].

Intervention

Physical therapy in this study consists of physical agents (20 min), manual therapy (30 min), and supervised exercises (60 min). The physical therapy intensity is 110 minutes per session 3 times a week for a total of 5 weeks.

Physical agents consists of infrared (IR-2014, AJINMEDICAL, Jeonju, Republic of Korea), microwave (Hanil-TM, Seoul, Republic of Korea), and transdermal nerve electrical stimulation (TENS) (Hanil-TM, Seoul, Republic of Korea), and a total of 20 minutes. The patient applies TENS and infrared simultaneously for 15 minutes in a sitting position[15, 16]. After treatment, microwave is continued for 5 minutes. Infrared are applied to the patient's right shoulder at a distance of 50cm with moderate heat intensity. TENS was set at 100~300 Hz, and then microwave was applied at a distance of 20cm at 2,450 MHz and 100 W[17].

Manual therapy releases the upper back and posterior neck for the patient's relaxation. Soft tissue mobilization is used mainly for global muscles that become tight and weak (biceps brachii, deltoid, pectoralis major, pectoralis minor, subscapularis, rhomboid minor, latissimus dorsi)[18]. For joint mobilization, anterior to posterior glenohumeral joint mobilization is performed in the supine to prevent adhesion of the posterior aspect of the glenohumeral joint capsule[19]. Then, inferior gliding or superior gliding is performed depending on the angle to increase the range of flexion and abduction. For scapular dyskinesis, scapulothoracic joint mobilization makes movement so that downward rotation is smooth[20].

Supervised exercises consist of stretching, strengthening, and stabilization exercises. For stretching exercise, considering the chain reaction and postural characteristics, the muscles to be stretched are the pectoralis muscles, latissimus dorsi, upper trapezius, and levator scapulae[21]. Strengthening exercise and stabilization exercise aimed to make normal scapulohumeral rhythm by actively reflecting scapular dyskinesis and conscious correction of scapular orientation[22, 23].

Results

During the 5 weeks of physical therapy intervention, no side effects occurred and overall positive improvement was observed. The results are summarized in Table 1.

The examination investigated pain intensity, ROM, function, and muscle strength as shown in figure 1. In follow-up, only pain intensity and shoulder function in the form of self-report questionnaires were examined. In the evaluated results, the pain intensity decreased from 4 to 1 point in the usual pain and decreased from 6 to 4 point in the worst pain. ROM was all increased, and the function also decreased from 8 to 4 point, indicating improved functions. The grip strength was also increased by 13kg after the intervention.

Discussion

Although numerous rehabilitation protocols have been proposed after ARCR, the main trend of studies is underpinning the immobilization phase, which is the time to start active movement[24, 25]. However, in this case report, graft augmentation is added instead of general ARCR. In addition, the muscle vector changes according to the change in the muscle position after surgery, which has not been dealt with much until now. Therefore, it suggests that the composition and quality of rehabilitation should be considered.

As a result of the physical therapy performed in this case report, it can be a practical method in hospitals and exercise centers in the tendon recovery process, and there were no reported side effects during the implementation. The evaluated results are shown in Table 1. Positive improvement stood out in all results. The results of each are as follows. Considering that the reported minimal important difference (MCID) of pain intensity was 1.1 to 2.17 points[9, 26], it was found that the reduced result in this study was a clinically significant result. In shoulder ROM, even compared with other case report studies[27], the increase in baselines appears to be quite large. Considering that the reported MCID of SST was 2 points in the shoulder function[28], a reduction of 4 points in follow-up compared to baseline is a clinically meaningful result. The fact that grip strength was confirmed by muscle strength was highly correlated with rotator cuff strength[29]. Therefore, the 13kg increase in grip strength indirectly means the improvement of the rotator cuff strength.

Patients who participated in this study visited 6 months after ARCR. This period is the final phase of the tendon healing process, the consolidation and/or remodeling phase[13]. As collagen becomes more dense and organized, scar strength increases[30]. Therefore, in this phase, aggressive stretching or strong loading with compensatory motion rather than normal motion may cause re-tear[31]. The functions of supraspinatus are abduction and external rotation, and in a study comparing normal adults and patients with shoulder impingement syndrome, supraspinatus also plays a depressive role to prevent impingement from occurring in the subacromial space (Figure 4)[32]. However, a patient who received additional graft augmentation may suspect that the structurally modified muscle may have an altered vector as shown in Figure 3B. This was estimated through elevation of only compensatory motion due to severe scapular dyskinesis during forward flexion at 6 months.

Therefore, based on the improved results in this study, it is judged that release for the large moment arm[33] that makes compensatory motion in the intervention protocol was effective. Also, to normalize scapular dyskinesis, conscious correction for scapular orientation is considered to have affected the muscle vector.

Conclusion

This study is the first study to clinically suggest compensatory motion due to scapular dyskinesis, which can be overlooked in postoperative rehabilitation of ARCR. As a result, chronic pain and movement limitation in ARCR with graft augmentation patients can bring positive improvements in pain intensity, range of motion, function, and strength through physical therapy management.

Conflicts of interest

The authors declare no conflict of interest.

Figures
Fig. 1. Sequencing flow plot
Fig. 2. Magnetic resonance imaging before and after arthroscopic rotator cuff repair. (A) Imaging before surgery, (B) Imaging after surgery.
Fig. 3. Muscle vector as seen in magnetic resonance imaging.
(A) Imaging before surgery, (B) Imaging after surgery.
Fig. 4. Depression of supraspinatus during shoulder abduction. Image from Muscles & Kinesiology (Muscle 8.0.76, Visible body, USA)
Tables

Table 1

Pain intensity, range of motion, function, and grip strength of the patient's right shoulder.

Measurement Baselines Post-test Follow-up
Pain intensity (point)
Usual pain 4 2 1
Worst pain 6 6 4
Range of motion (°)
Forward flexion 87 168
Scaption flexion 95 170
Abduction 67 144
Internal rotation 23 40
External rotation 0 27
Shoulder function (point)
SST 8 6 4
Muscle strength (kg)
Grip strength 28 41

SST: simple shoulder test.


References
  1. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94:227.
    Pubmed KoreaMed CrossRef
  2. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77:10-5.
    Pubmed CrossRef
  3. Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Indications for rotator cuff repair: a systematic review. Clin Orthop Relat Res. 2007;455:52-63.
    Pubmed CrossRef
  4. McCarron JA, Derwin KA, Bey MJ, Polster JM, Schils JP, Ricchetti ET, et al. Failure with continuity in rotator cuff repair “healing”. Am J Sports Med. 2013;41:134-41.
    Pubmed CrossRef
  5. Chalmers PN, Tashjian RZ. Patch augmentation in rotator cuff repair. Curr Rev Musculoskelet Med. 2020:1-11.
    Pubmed KoreaMed CrossRef
  6. Ditsios K, Boutsiadis A, Kapoukranidou D, Chatzisotiriou A, Kalpidis I, Albani M, et al. Chronic massive rotator cuff tear in rats: in vivo evaluation of muscle force and three-dimensional histologic analysis. J Shoulder Elbow Surg. 2014;23:1822-30.
    Pubmed CrossRef
  7. Sato EJ, Killian ML, Choi AJ, Lin E, Esparza MC, Galatz LM, et al. Skeletal muscle fibrosis and stiffness increase after rotator cuff tendon injury and neuromuscular compromise in a rat model. J Orthop Res. 2014;32:1111-6.
    Pubmed KoreaMed CrossRef
  8. Kikukawa K, Ide J, Kikuchi K, Morita M, Mizuta H, Ogata H. Hypertrophic changes of the teres minor muscle in rotator cuff tears: quantitative evaluation by magnetic resonance imaging. J Shoulder Elbow Surg. 2014;23:1800-5.
    Pubmed CrossRef
  9. Michener LA, Snyder AR, Leggin BG. Responsiveness of the numeric pain rating scale in patients with shoulder pain and the effect of surgical status. J Sport Rehabil. 2011;20:115-28.
    Pubmed CrossRef
  10. Norkin CC, White DJ. Measurement of joint motion: a guide to goniometry: FA Davis; 2016.
  11. Veeger H, Van Der Helm F. Shoulder function: the perfect compromise between mobility and stability. J Biomech. 2007;40:2119-29.
    Pubmed CrossRef
  12. España-Romero V, Ortega FB, Vicente-Rodríguez G, Artero EG, Rey JP, Ruiz JR. Elbow position affects handgrip strength in adolescents: validity and reliability of Jamar, DynEx, and TKK dynamometers. J Strength Cond Res. 2010;24:272-7.
    Pubmed CrossRef
  13. Magee DJ, Zachazewski JE, Quillen WS. Scientific foundations and principles of practice in musculoskeletal rehabilitation-E-book: Elsevier Health Sciences; 2007.
  14. Neumann DA. Kinesiology of the musculoskeletal system-e-book: foundations for rehabilitation: Elsevier Health Sciences; 2016.
  15. Bellew JW, Michlovitz SL, Nolan Jr TP. Michlovitz's modalities for therapeutic intervention: FA Davis; 2016.
  16. Wang G, Xu Y-m, Ye D-m, Fu T-f, Zou Y-z, Feng X-x, et al. Effects of different doses of microwave therapy on adjacent tissue of titanium alloy implants after fracture surgery. Chinese J Tissue Eng Res. 2018;22:1072.
  17. Johnson M. Transcutaneous electrical nerve stimulation: mechanisms, clinical application and evidence. Rev Pain. 2007;1:7-11.
    Pubmed KoreaMed CrossRef
  18. Bullock-Saxton J, Murphy D, Norris C, Richardson C, Tunnell P. The muscle designation debate: the experts respond. J Bodyw Mov Ther. 2000;4:225-41.
    CrossRef
  19. Itoi E, Arce G, Bain GI, Diercks RL, Guttmann D, Imhoff AB, et al. Shoulder stiffness: current concepts and concerns. Arthroscopy. 2016;32:1402-14.
    Pubmed CrossRef
  20. Kibler WB, Sciascia A. Current concepts: scapular dyskinesis. Br J Sports Med. 2010;44:300-5.
    Pubmed CrossRef
  21. Barroqueiro C, Morais NV. The effects of a global postural reeducation program on an adolescent handball player with isthmic spondylolisthesis. J Bodyw Mov Ther. 2014;18:244-58.
    Pubmed CrossRef
  22. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. Br J Sports Med. 2010;44:319-27.
    Pubmed CrossRef
  23. De Mey K, Danneels L, Cagnie B, Huyghe L, Seyns E, Cools AM. Conscious correction of scapular orientation in overhead athletes performing selected shoulder rehabilitation exercises: the effect on trapezius muscle activation measured by surface electromyography. J Orthop Sports Phys Ther. 2013;43:3-10.
    Pubmed CrossRef
  24. Bandara U, An VV, Imani S, Nandapalan H, Sivakumar B. Rehabilitation protocols following rotator cuff repair: a meta‐analysis of current evidence. ANZ J Surg. 2021.
    Pubmed CrossRef
  25. Fu MC, O'Donnell EA, Taylor SA, Aladesuru OM, Rauck RC, Dines JS, et al. Delay to arthroscopic rotator cuff repair is associated with increased risk of revision rotator cuff surgery. Orthopedics. 2020;43:340-4.
    Pubmed CrossRef
  26. Mintken PE, Glynn P, Cleland JA. Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain. J Shoulder Elbow Surg. 2009;18:920-6.
    Pubmed CrossRef
  27. Kim J-H, Kim J-I, Lee H-J, Kim D-J, Sung GY, Kwak D-H, et al. Long-term follow-up of extensive peri-anchor (Poly-L/D-lactic Acid) cyst formation after arthroscopic rotator cuff repair: a case report. Clin Shoulder Elb. 2019;22:100.
    Pubmed KoreaMed CrossRef
  28. Tashjian RZ, Deloach J, Green A, Porucznik CA, Powell AP. Minimal clinically important differences in ASES and simple shoulder test scores after nonoperative treatment of rotator cuff disease. J Bone Joint Surg Am. 2010;92:296-303.
    Pubmed CrossRef
  29. Horsley I, Herrington L, Hoyle R, Prescott E, Bellamy N. Do changes in hand grip strength correlate with shoulder rotator cuff function? Shoulder Elbow. 2016;8:124-9.
    Pubmed KoreaMed CrossRef
  30. Killian ML, Cavinatto L, Galatz LM, Thomopoulos S. The role of mechanobiology in tendon healing. J Shoulder Elbow Surg. 2012;21:228-37.
    Pubmed KoreaMed CrossRef
  31. Burmaster C, Eckenrode BJ, Stiebel M. Early incorporation of an evidence-based aquatic-assisted approach to arthroscopic rotator cuff repair rehabilitation: Prospective case study. Phys Ther. 2016;96:53-61.
    Pubmed CrossRef
  32. Halder A, Zhao K, O'driscoll S, Morrey B, An K. Dynamic contributions to superior shoulder stability. J Orthop Res. 2001;19:206-12.
    CrossRef
  33. Steenbrink F, Meskers CG, Nelissen RG, De Groot JH. The relation between increased deltoid activation and adductor muscle activation due to glenohumeral cuff tears. J Biomech. 2010;43:2049-54.
    Pubmed CrossRef

 

Full Text(PDF) Free

Cited By Articles
  • CrossRef (0)
  • Authorship and ethical issues