I had a 6 week post-op RTC repair middle-age female patient arrive to my clinic for evaluation just recently on a Monday morning.  The Friday prior, she had returned to her surgeon who doffed her abduction sling completely (6 weeks seemed like a long time but not the point here).  No details were given to me about the procedure (such as size of tear, if he even performed a SAD or DCE; just knew it was an arthroscopic approach).  The patient did tell me that the surgeon said he had to “extract” the tendon so I am assuming a large tear (possibly reason for long sling wear). She had only been performing elbow flexion/extension and Codman exercises as prescribed by her surgeon for the last 3-4 weeks, otherwise, no other specific activity.  She had returned to her desk job a few weeks prior.

She has not had a significant amount of pain per her report since the surgery but pain has exponentially increased since doffing sling (pain rating up to 8/10 on NRPS).  The location of pain was not as typical as I would see around shoulder cap  but mid-brachium anteriorly.   The posture was observed as significant difference in shoulder height on involved side (basically depressed) with guarding of the involved limb across her torso in GH adduction/IR and ante-brachium in pronation.  She had pretty much no voluntary ability to lift arm off of thigh in sitting. 

Passive ROM was significantly limited with only ~ 15 degrees of elevation and ER was limited to negative 30 degrees (yes, negative).  I get very concerned with the lack of ER in particular as I find this is a huge indicator of freezing shoulder starting to arise (not uncommon for a female, middle-age who was recently immobilized).  Read a past post here.  Nevertheless, any type of movement was painful to her; including scapular active range of motion.  Attempts of passive ROM via therapist was poorly tolerated with again pain in mid-brachium and not in the “joint” (harder to treat in her main complaint location!).  Not too much of a response either from a retrograde myofascial release of the lateral deltoid and biceps brachii or 1st rib and lower cervical spine mobilizations. 

With a doctoral intern accompanying me, the first thought of treatment was to provide distraction.  This is usual right as it is pain-relieving?  Not in this case and we decided to go the opposite direction.  Compression.  

With a squeeze grasp approach at the upper end of the humerus and a graded axial load superiorly, I was able to “sit” the humeral head more comfortably in the glenoid fossa.  She had an immediate response with ability to tolerate passive ROM supine and even scapula active range of motion seated.  Pain instantly decreased to a 1-2/10 scale and she was prescribed seated scapula retraction with neck extension and shoulder shrug with self axial compression via contralateral arm.  Also, codmans was modified to a “baby cradle” hold (which was much more comfortable for her).

It appeared that her humeral head was basically resting on the axillary pouch of the inferior glenohumeral ligament due to lack of any type of dynamic stability (she was very weak!).  Painful ER was possibly due to amount of stress that this ligament was already enduring and the anterior band could not help assist with keeping humeral head seated in glenoid as it rolled anteriorly. Providing the heel of my hand over the anterior aspect of humeral head during ER helped some, but not significant unless I provided compression.  

I thought this was interesting and not a typical manual approach for post-op RTC repair.  Hope you enjoyed!  

 

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3 comments

    1. Thanks for the comment Peter. No, we do not have aquatic therapy on site so wasn’t an immediate option. I normally would not even think about it status-post RTC but definitely can be an option!

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