PFATS Articles

Recovering From Multiple Surgeries: A Case Study

James Collins Jr., ATC, Aaron Miller, ATC, and Damon Mitchell, ATC
San Diego Chargers Athletic Training Staff

The following case study involves a 23-year-old San Diego Chargers defensive lineman who experienced multiple injuries and surgeries during the 2004 season. Recovering from injury is always stressful both mentally and physically. In general, most athletes are able to recover from one season-ending injury. However, full recovery from three major surgeries in a single season is a much greater challenge, especially for a rookie. This athlete was able to overcome all three surgeries in just nine months.

The sequence of events that follows is based upon the timing of surgery and the effect that each surgery had on the recovery and rehabilitation of each injury. Three surgeons were involved in the recovery process and their subsequent rehabilitation protocols influenced the sequence in which we were able to start and progress his rehabilitation. The athlete suffered the following three injuries.

• Lumbar Spine L5-S1 Herniated Nucleous Pulposus with Radiculopathy detected during combine physicals.
• Right Shoulder DJD with Recurrent Subluxation suffered during the first regular season game.
• Right Great Toe Flexor Hallucis Brevis Tendon Tear with Lateral Sesmoid Fracture that ended his 2004 season.

The athlete was drafted in 2004 with a pre-existing history of a L5-S1 disc herniation. During the first game of the 2004 season, he sustained a right shoulder subluxation. Following the shoulder subluxation, the athlete continued to play wearing a protective shoulder harness during contact. In addition, the athlete participated in pre-operative shoulder rehabilitation to maintain strength. During the fifth regular season game, he sustained a season-ending injury to his right great toe. After suffering his toe injury, the sports medicine staff and the athlete decided that at the proper time following the right great toe surgery, he would undergo lumbar spine surgery followed by surgery to his right shoulder.

First Surgery: Right Great Toe Flexor Hallucis Brevis Tendon Repair

As stated earlier, the lineman suffered the toe injury to end his rookie season. Since this injury was the most acute and debilitating, the sports medicine staff decided to repair the tendon immediately. During a game between the San Diego Chargers and the Atlanta Falcons, the defensive lineman came off the field complaining of pain in his right great toe. He stated that when he pushed off the line of scrimmage, he felt a “pop” in the bottom of his foot. He was examined by Dr. David Chao on the sideline and was immediately sent for x-rays. Lateral and AP views revealed a fracture of the lateral sesmoid with a 1 cm displacement and bone fragments. The mechanism of injury was forced hyperextension to the metatarsal-phalangeal joint.

The following day, the player had an MRI of his right foot that again demonstrated a fracture of the lateral (fibular) sesmoid along with a myotendinous tear of the lateral head of the flexor hallucis brevis muscle. The MRI also showed a contusion to the medial (tibial) sesmoid, but no discrete fracture, and a rupture of the plantar plate. The following Tuesday, the lineman was sent to see a foot specialist who determined that the best course of action was surgical intervention for the removal of the fractured lateral sesmoid.

Once the initial incision had been made, it was determined that the flexor hallucis brevis muscle had ripped off the medial sesmoid and could not be repaired. Therefore, the medial sesmoid and fragments of the fractured lateral sesmoid were all removed. A 3.5 mm corkscrew with #2 FiberWire was inserted into the proximal phalanx with the suture woven back and forth through the flexor hallucis brevis tendon. This procedure restored the function of the flexor brevis mechanism.

The athlete was placed in a cam walker and instructed to be non-weight bearing for the first three weeks following surgery. The athlete progressed to begin weight bearing for the next three weeks. Because of the flexor hallucis brevis repair, the rehabilitation process was put on hold for 6 weeks. By the seventh week, passive range of motion (PROM) stretching at the MP joint was initiated in an attempt to regain fully functional flexion and extension. Modalities and therapeutic massage were also utilized in this process. Light manual resistance exercises as well as proprioceptive activities were added as tolerated. As the active range of motion (AROM) and strength of the great toe improved, more functional activities like toe raises, step-ups, and single leg squats were added. At this point in the rehabilitation process, the only limitations were determined by a lack of range of motion (ROM) or strength. Ultimately, the athlete’s foot rehabilitation was suspended to correct the athlete’s lumber-spine injury.

Second Surgery: Laminectomny and discectomy

During the pre-season physical and first noted at the NFL Combine, it was discussed with the athlete that he had a herniated disc in his lumbar spine resulting from a previous injury in college. Following the exam, it was also concluded that he had symptomatic lumbar-spine radiculopathy. He was still able to function, experiencing some discomfort, and had performed lumbar stabilization exercises in the past. He had decreased ROM with straight leg raise (SLR) accompanied by intermittent lumbar pain and hamstring tightness. It was recommended that he continue with the lumbar stabilization program in an attempt to finish the season. The athlete’s CT revealed a moderate 5 to 7mm left posterolateral disc protrusion, nearing the left lateral spinal recess and affecting the left SI nerve root. The pre-operative diagnosis was a left L5-S1 herniated nucleus pulposes with radiculopathy and the surgery performed was a left L5-S1 laminotomy and discectomy.

Two months following his foot procedure, the athlete underwent surgery on his lumbar spine for a left L5-S1 laminectomy and discectomy. The post-operative findings showed left sided L5-S1 herniated disc fragments impinging and displacing the left S1 nerve root. Inflammatory appearance of the left S1 nerve root was also noted. As we mentioned, it was at this time that progression of his toe rehabilitation ceased until he was cleared for functional activity by the spine specialist.

The rehabilitation from this lumbar surgery is as follows:

• Week 1–3
  Avoid trunk flexion and extension ROM and strengthening exercises.

• Week 3–5
  Begin passive hamstring stretching and light abdominal exercises in pelvic neutral. The exercise bike can also be added for cardiovascular conditioning.

• Week 6–9
  Start the lumbar/pelvic stabilization program with continued limitations in full trunk flexion and extension. Continue using the exercise bike in addition to the aquatic therapy program for cardiovascular conditioning.

• Week 9–12
  Increase the intensity of the lumbar/pelvic stabilization program and add light to moderate weight lifting.

• Months 4–5
  Continue with the lumbar/pelvic stabilization program and increase weight lifting as tolerated.

• Months 5+
  Begin with straight ahead running at five months with gradual progressions, the addition of lateral movements and more intense functional activities. He also began running in the SwimEx and performing pool workouts on alternating days.

Once cleared by a spine specialist, the player began more functional activities for both core strengthening and lower extremity strengthening including:

• Jump Rope
• Plyo-sled Bounds
• Rebounder
• Sport Cord Walkout
• Plyometrics

Third Surgery: Right Shoulder DJD

Following the spine surgery and rehabilitation, the athlete underwent his third and final surgery for a right shoulder labral repair. The shoulder is the most commonly subluxed joint in the body. In the first game of the season, the athlete who had no history of shoulder pathology was involved in a defensive run play. He was engaged with an offensive lineman with both of his shoulders flexed to 90°. He exposed his right shoulder to prepare to take on a second block by the running back. Once engaged with the running back, he immediately lost his balance and fell to the ground on his left shoulder, while still engaged with the offensive lineman. As the offensive lineman fell on top of him, his right shoulder was forcefully abducted and externally rotated with his elbow flexed at 90° causing his shoulder to absorb all the force.

On exam by the team orthopedist, pain was elicited with specific shoulder movements and special tests. Once determined by physical examination that he had anterior shoulder laxity; he was placed in a protective shoulder harness that limited external rotation at 0° and 90° of shoulder abduction. He was allowed to return and finish the game.

Following the game, the player was sent to x-ray for further evaluation. The films verified that there was no sign of a fracture. Ice was applied to the shoulder for 30 minutes and the team physician administered oral narcotics and NSAIDS for pain and inflammation. The player traveled back with the team and was scheduled for an MRI the next morning.

The MRI revealed two injuries within the glenohumeral joint complex. The radiologist identified a tear of the anterior labrum with associated sprain of the middle glenohumeral ligament. Also, there was a sprain of the anterior and posterior bands of the inferior glenohumeral ligament, but there was no complete tear or discontinuity.

As part of his pre-operative program, he began his rehabilitative program two days after he sustained the injury. During the first week of rehabilitation, the athletic training staff began to increase his PROM along with isometric and isotonic strengthening. It was not until the end of the first week of rehabilitation that passive internal and external rotation at 0° of shoulder abduction was introduced. By week two he continued without any residual problems. He had full active AROM except for internal and external rotation at 0° and 90° of shoulder abduction. The exercises that were added to the program were dumbbell and manual resistance flexion, extension, abduction, adduction and horizontal flexion and extension along with shoulder PNF and proprioceptive exercise. In the following week, exercises were added to the program as he tolerated. The exercises that were added were internal and external rotation and manual resistance exercises at 90° of shoulder abduction, isokinetic internal and external rotation strengthening, physioball push-ups, and upper body position specific bag drills. Remarkably, the athlete missed only one day of practice and played in every game during his shoulder pre-operative rehabilitation.

The labral repair went as planned in early January of 2005 after undergoing foot and spine surgery. Examination under anesthesia was in accord with the post game orthopedic evaluation and MRI findings. Those findings indicated his shoulder had a good end point and anterior laxity; also, no significant inferior laxity and full range of motion. The intra-articular inspection revealed two large chondral loose bodies: one in the subscapularis recess and one anteriorly in the shoulder joint. There was also grade three chondromalacia centrally across the entire glenoid. The cartilage of the humeral head was normal except for the posterior aspect where there was a 2x3 cm area of grade four chondromalacia (full thickness cartilaginous defect). There was labral fraying of the superior labrum anterior and posterior (SLAP) as well. The labral tear was debrided over 60° anteriorly, inferiorly and posteriorly. A chondroplasty was performed over the entire glenoid and over the posterior aspect of the humeral head. There were loose bodies removed and a microfracture of the posterior aspect of the humeral head was performed. The rehabilitation process following surgery is outline below:

• Weeks 1–4
  The first phase of rehabilitation was a relatively slow, waiting process. Because there was a microfracture procedure performed, he was immobilized for two weeks before the athletic training staff could begin the rehabilitation program. He returned to the athletic training room four, eight, and 12 days post-op to change the sterile dressings that were applied after surgery. At two weeks post-op, he began PROM stretching without any external rotation, Codman’s pendulums, and active assisted manual therapy.

• Months 2–4
  At this phase of the rehabilitation program, the athletic training staff was able to accelerate the program due to the fact that he regained full AROM. There were no contraindications with his shoulder rehabilitation at this point. He continued to increase the intensity of all manual resistance, sport cord, and dumbbell exercises, along with doing scapular and shoulder PNF, and opened and closed chained proprioceptive exercise.

• Month 5
  During this final stage of rehabilitation, he began regular isotonic upper body strengthening with no restrictions. Once he was cleared by the spine specialist following the lumbar-spine surgery, he was then able to begin field work activities including: cone drills, bag drills, ladder drills, and position specific activities. At this point, running was incorporated into the conditioning component of his rehabilitation which consisted of half gassers, 100 yard striders, 50 yard sprints up a hill, and the resistance rope. As he progressed and increased his cardiovascular strength and endurance, we added some work with tackling dummies, the sled, and then one-on-one drills with an offensive lineman. We were able to ease the athlete back into practice during a rookie mini-camp just before the start of the 2005 training camp.

  

  In order to return the athlete to full participation, the athletic training staff focused on functional activity incorporating rehabilitation for the toe, spine and shoulder. Focusing on return to play, he participated in one practice a day and used the other practice to perform a lower body circuit or a pool workout. After this two week training camp routine, the athlete was ready for his first real challenge of competing when the Chargers traveled to Lambeau Field to take on the Green Bay Packers.