PFATS Articles

A Case Study in the Rehabilitation and Time Management of Simultaneous Upper and Lower Extremity Surgeries

Reggie Barnes, MS, ATC
Director of Rehabilitation/Associate Athletic Trainer
Seattle Seahawks

Introduction

Injuries that occur in the National Football League often require surgical care in order for the injured athlete to have a successful and safe return to the field. In the rare cases when players have multiple surgeries during or after a season, management of care has to be well timed to allow for healing from one surgery to the next. The sports medicine staff must pay attention to time management to ensure a successful outcome of the rehabilitation program.

In this case, a defensive safety had post-season surgery on his left shoulder to repair his labrum and biceps tendon, as well as surgery to both of his ankles to remove bone spurs and loose bodies. Although these conditions presented themselves during the season, they did not require surgical intervention at that time, and he continued to participate in practices and games. The sports medicine staff decided that corrective surgery for his shoulder would take place immediately following the conclusion of the season in early January, and the corrective surgery for both of his ankles would be done approximately three months following his shoulder surgery, with each ankle surgery taking place ten days apart.

Anatomical Review:

Shoulder

The shoulder joint has a rim of cartilage called a labrum that surrounds the socket of the scapula where the humeral head sits. The labrum circles the shallow shoulder socket (the glenoid) to make the socket deeper. This rim of cartilage makes the shoulder joint much more stable and allows for very wide range of motion.

Ankle

The ankle is composed of three bones, the talus, distal tibia and fibula. The distal tibia, medial malleolus, and lateral malleolus comprise the ankle mortise. The talar dome fits into the mortise to complete the bony components of the ankle.

Definition and Mechanism of Injury:

Shoulder

The athlete had what is diagnosed as a superior labrum from anterior to posterior (SLAP Tear) in his labrum, along with some fraying of the biceps tendon. A SLAP tear occurs at the point where the tendon of the biceps muscle inserts on the labrum. At the location of most SLAP tears, there is usually a poor blood supply, so healing is not likely. Typical symptoms of a SLAP tear include a catching sensation and pain with most overhead activities. Athletes usually complain of pain deep within the shoulder or in the back of the shoulder joint. In cases of SLAP tears with associated biceps tendonitis, athletes may complain of pain over the front of the shoulder.

Ankle

The athlete developed anterior impingement syndrome due to the build up of bone spurs along the front of the tibia. Bone spurs often form because of repetitive anterior ankle joint compression during dorsiflexion. The resulting repetitive compression injury caused soft tissue ossification along the anterior tibia and talus, forming the bone spurs. Anterior tibiotalar impingement often presents itself as anterior ankle pain that worsens with active ankle dorsiflexion. Clinically, the athlete presents with decreased ankle dorsiflexion and pain with full plantarflexion.

Evaluation and Assessment:

The clinical evaluations for both of these conditions were confirmed by X-Ray and MRI imaging. Arthrogram MRI of the left shoulder revealed a SLAP (Type V) tear extending from the posterior superior labrum to the anterior superior labrum to the anterior/inferior labrum exposing an 8 x 6 mm anterior inferior glenoid chondral lesion and chondral flap tear. Although the MRI showed some swelling around the biceps tendon, there was no tear.

X-Ray images of the left and right ankles revealed anterior ostephytes of the tibia. MRI films confirmed anterior osteophytes with some mild anterior ankle edema. The athlete completed a strengthening program for his shoulder and ankles in an effort to help him through the season. Weekly evaluations were conducted to ensure that he was functionally stable and strong enough to continue to participate at a high level without risking injury to himself or other players. His evaluations included manual muscle tests, functional measurements, and special test maneuvers to determine if there was any worsening of his conditions. Non-steroidal anti-inflammatory drugs were utilized as needed to manage pain and swelling.

Treatment and Surgery:

During the season, the sports medicine staff administered conservative treatment which consisted of strengthening programs for the rotator cuff and lower leg musculature. Heel lifts were placed in all of his shoes. Both the shoulder and ankle surgeries were done arthroscopically. The shoulder surgery consisted of a biceps tendon debridement along with a repair and suture anchoring of the labrum. The ankle surgery consisted of a debridement and removal of the loose bodies and bone spurs.

Rehabilitation:

Coordinating the rehabilitation for the three surgeries required careful planning, flawless execution, and a high level of commitment from the athlete. The initial goal of the sports medicine staff was to rehabilitate the shoulder so that the athlete could support himself and perform activities of daily living without assistance before undergoing surgery for his ankles. For ambulation during the non-weight bearing phases of rehabilitation for each of his ankles, the athlete utilized a Turning Leg Caddy® . The use of this device eliminated any concerns regarding the use of crutches and the impact there use would have on the newly corrected shoulder. Different shoulder exercises had to be incorporated once the ankles were corrected due to the fact that standing was not always an option for performing rehabilitation exercises. Two weeks prior to the ankle surgeries, the athlete began a “pre-hab” program for the ankles to strengthen them in an effort to hasten the post surgical recovery time.

Shoulder surgery rehabilitation protocol:

Week 1

Healing of surgical incision
Gameready® unit to control pain and swelling

Weeks 2 to 8

30 degrees external range of motion (ROM) restriction
Isometric exercises strengthening the rotator cuff musculature
Wrist strengthening to maintain forearm and grip strength
Scapular retractions, shrugs, and the use of a pulley system to promote early range of motion

Weeks 8 to 16

Increase ROM without post surgical sling.
Upper-body ergometer for pre-exercise warm up and joint nutrition through movement
Stretching of the rotator cuff
Strengthening exercises:

Cardinal planes
Serratus punches
Internal/external rotation with tubing
Dynamic stabilization
Prone rows
D1 and D2 pattern strengthening
Dumbbell bench press on the floor

Biceps and triceps strengthening
Aquatic therapy

During this phase, the left ankle surgery was performed followed by right ankle surgery ten days later. During each session, the athlete began his rehab for the ankles followed by the shoulder program, so that the athlete could maintain a continuous flow of exercises for each body part. Avoiding a “start-and-stop” kind of rehabilitation program promotes a concise and directed method of movement through each exercise. It also keeps the respective body part and surrounding soft tissue “warmed up”, providing a better comfort level for the athlete. This is important for any rehabilitation program in respect to promoting a high level of confidence for the athlete. Most of the exercises for the shoulder that required standing could still be completed because the athlete could lock out the wheels on the Leg Caddy® and evenly distribute his weight on both legs.

Week 16: Return to Activity

Initiate normal weight room lifting
Begin functional/sports specific exercises

Medicine ball drills
Target mitt drills
Various punching activities.

On-field running (once both ankles were cleared by the team physician)
Position specific & sled drills

The athlete was able to participate on a limited basis during the June mini-camp and fully participated in training camp.

Ankle rehabilitation program protocol:

Week 1

Healing of surgical incision
Gameready® unit to control pain and swelling
Intermittent compression unit to decrease swelling (after incisions were fully healed)

During the five day non-weight bearing period, table exercises for the hip and knee were performed and included straight leg raises, terminal knee extensions, ball squeezes and glute extensions.

Weeks 2 to 4

Weight bearing exercises
Ankle strengthening exercises

Ankle tubing
Single leg balance
Toe curls & pick-ups
Heel & toe walking
Shuttle calf raises

Week 4: Return to activity

Functional activity

Jump rope
Single leg bounding on the shuttle
Treadmill running
Position specific drills on the field

When managing any rehabilitation program for an athlete, it is important to keep an open mind and be creative with the exercises. Varying the programs daily, especially with long rehabilitations, is essential to keeping the athlete interested and highly motivated during the processes of healing, strengthening, functional activity and return to practice and play.

Resources

Frontera, W. et al. (2007). Clinical Sports Medicine: Medical Management and Rehabilitation. Philadelphia, PA: Elsevier, Inc.
Nam, E.K. & Snyder, S.J. (2003) Clinical Sports Medicine Update: The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J Sports Med. 31, 798 - 810.