Introduction
The number of rotator cuff tear patients is gradually increasing [1], and surgical repair is often performed first. However, due to the increase in the life expectancy of patients and the increase in sports activities, it is not uncommon to re-tear after surgery [2]. In particular, there is a limit to repairing again after re-tear, so conservative treatment or total arthroplasty is usually considered [3]. Therefore, if the rotator cuff is re-teared after one repair operation, rehabilitation exercise treatment for functional recovery would be a necessary treatment. However, the rehabilitation exercise protocol is being implemented in various ways in each hospital, and the rehabilitation program in a long-term way has not yet been established.
Therefore, we would like to present the rehabilitation journey during the 7-year follow-up of patient who underwent arthroscopic repair surgeries twice with two rotator cuff tears in the same area, and to illustrate the specific rehabilitation exercise protocol provided to the patient.
Case Report
A 46-year-old male patient underwent arthroscopic rotator cuff repair surgery on his right shoulder at an orthopedic clinic due to right shoulder pain that lasted for four months and visited one rehabilitation center. Two years before the visit, he had already undergone an arthroscopic repair once on the same shoulder due to full thickness tear of supraspinous tendon, and secondary repair was performed due to the findings of re-tear of the supraspinous tendon. There were symptoms that felt like touching while moving the arm and pain of NRS 5 before surgery.
He had been working out twice a week since his late 20’s. His workout consisted of mainly bench press or other upper extremity strengthening exercises. When he was 36 years old, he could not maintain his workout due to post exercise pain on both shoulder regions. Five years after that, he had started to play ice hockey and to do Pilates. He had played ice hockey for 2 hours a day and had done Pilates one hour per day twice a week before the first shoulder surgery. The Pilates program was both shoulder active resistive ROM exercise with Thera band for 40 minutes after 20 minutes massage around shoulder. One day he had experienced a big crash while playing ice hockey game. After that crash he could not move both shoulder and diagnosed with rotator cuff tear. At this time, after undergoing the first arthroscopic rotator cuff tear repair surgery on both sides, the pain improved and exercise was restarted. Two years later, after hitting his shoulder again, he was diagnosed with a right rotator cuff re-tear and underwent this second arthroscopic repair surgery (Fig. 1).
After second surgery both shoulder had 10 degrees of forward flexion, 15 degrees of abduction, less than 10 degrees of external and internal rotation in evaluation with a goniometer. The muscle strength of shoulders was grade 2 in all directions of movements. All passive range of motion of both shoulder could not be measured due to severe pain at that time.
MRI performed after surgery showed that 2/1/0/0 grade atrophy of fat infiltration [4] of supraspinatus/infraspinatus/teres minor/subscapularis muscles, supraspinatus tendon was well attached in GT area, and another unusual post-op change was not seen (Fig. 2). In the arthroscopic findings, retraction of supraspinous tendon revealed exposure of it’s insertion site and loosening of the previous surgical suture materials (Fig. 3).
Rehabilitation exercise program was under the physician’s supervision at cooperative rehabilitation center according to rehabilitation protocol 3 times a week (Table 1). Exercise was largely divided into three phases according to the painless shoulder abduction angle. Initially, not all phases and sets were completed, but the number and intensity could be gradually increased.
In the first phase of the exercise program, it mainly focused on strengthening the muscles of the lower extremities and the trunk. After the exercise of the first phase was completely performed without pain, the second phase exercise was started. The second phase of exercise mainly focused on strengthening the large muscles behind the upper and lower back. The last three stages of exercise included small muscle exercises for the muscles that actually make up the shoulder girder and the rotor cuff. A patient had workout 3 times a week, every session was nearly one hour. After 2 years rehabilitation exercise, he finally achieved full recovery of right shoulder function.
MRI performed after rehabilitation treatment showed a supraspinous tendon thinning but maintaining continuity, and another tear in the other cuff teandons was not reported, and 2/2/0/0 grade atrophy of fat infiltration of supraspinatus/infraspinatus/teres minor/subscapularis muscles (Fig. 4). This was confirmed to be 18 mm on both the left and right sides of the supraspinous muscle thickness measured by ultrasound (Fig. 5). Compared to before surgery, the thickness of the deltoid muscle increased from 19.2/10.7/33.4 mm to 21.8/16.0/54.6 mm in the anterior/middle/posterior muscles [5] (Fig. 6). Compared to the non-involved side in the isokinetic evaluation performed after rehabilitation treatment, there was no significant left-right difference in the peak torque and total work of the shoulder where the surgery was performed (Fig. 7).
Discussion
The rotator cuff tear is very common, and there are many patients who have undergone the repair surgery accordingly. Damage to rotator cuff muscles at a young age occurs in highly active people, and therefore, there is a high possibility of further damage due to sports activities even after repair surgery [6,7].
In the case of the patient discussed above, he is also a patient with high sports activities, and after first surgery, a second surgery was performed due to a re-tear of the same area. Therefore, other treatment methods other than repeated surgery will have to be found.
Like this case, it is low at 65.9% in the case of maintaining the similar high sports level as before after the rotator cuff repair surgery [8]. However, for athletes following return to play criteria based on sufficient time and muscle strength, a high degree of the successful return and low retear rate is shown [9]. Therefore, rehabilitation exercise treatment through strengthening surrounding muscles could prevent not only additional muscular atrophy of the shoulder but also failure to return to high-level sports.
Patients after rotator cuff injury show changes in scapular position (protraction, depression, external rotation), and changes in cervical and thoracic curves (kyphotic posture). As the dyskinetic movement of the scapular is associated with shoulder pain [10], strengthening of the large posterior muscles of the spine and back should be prioritized for rehabilitation exercise treatment.
As shown in the above patient, stabilization of posterior muscles such as deltoid (especially posterior part) and teres minor plays a crucial role in the functional recovery of the shoulder as much as maintaining the muscle strength and integration of the supraspinatus muscle [8].
As an additional issue, the rehabilitation journey for this case has been successful enough to improve function and continue sports activities without further impairment and significant pain. Pataky et al. reported movement compensation driven by the deltoid muscles following severe rotator cuff tear contributed to produce a desired improvement in function [11]. However, since deltoid hypertrophy, right side was prominently confirmed in MRI, and a slight upward transfer of the humeral head was confirmed, the possible progression to rotator cuff arthropathy on a long-term standpoint should be considered. Through long-term follow-up observation, it is necessary to carefully balance the benefits obtained through enjoying sports performance sufficiently, and the harm caused by the secondary damage of the shoulder joint and the deterioration of joint function in the long run.
