Rebecca Stevens

Case Study
11/14/2013
I.

Patient Data
a. Patient is a 49-year old Caucasian male.
b. Patient is a native English speaker.
c. Employment: Head custodian at a local school district.

II.

Etiology/Course of Pathology
a. Classical Presentation
All Classical Presentation information compiled from OrthoInfo, AAOS.org, and Radiology.org
i. Reverse Total Shoulder Arthroplasty (rTSA)
1. Details of rTSA
a. Highly technical shoulder replacement surgery.
b. Recommended for patients with cuff tear arthroplasty, a complex type of
shoulder arthritis.
c. A rTSA reverses the ball and socket components of the shoulder joint.
The Ball replaces the Glenohumeral joint and the socket replaces the humeral
head. A
d. The rTSA depletes the work load of the rotator cuff muscles and relies on the
deltoid muscle to move the joint.
2. Surgical Candidate Presentation:
a. Complete rotator cuff tear, irreparable
b. Cuff Tear Arthroplasty
c. Unsuccessful primary Total Shoulder Arthroplasty
d. Other treatment methods unsuccessful, such as Physical Therapy, pain
medication, and muscle repair.
3. Surgical Complications
a. Similar to other surgical procedures:
i. Infection
ii. Bleeding
b. Similar to other Arthroplasty procedures
i. Wear of the components
ii. Loosening of the components
iii. Dislocation of the joint
4. Recovery
a. Antibiotics to prevent infection
b. Release from hospital after 2-3 days, on average.
c. Solid foods immediately
d. Walking immediately
5. Rehabilitation
a. Sling for immediate use
b. Physical Therapy protocol, as per the surgeon
c. Dressing, eating, and grooming within a few weeks, dependent on physical
therapy protocol
d. Follow up appointments, including x-ray, appropriate
6. Outcomes
a. Generally, the shoulder will regain range of motion between 100 - 120
b. Pain relief is excellent

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Rebecca Stevens
Case Study
11/14/2013
c. No long-term studies currently exist

Figure 2 A typical follow-up x-ray

of a reverse total shoulder
replacement.

Figure 2 Rotator Cuff Tear MRI

ii. Motorcycle Accidents

All Classical Presentation information compiled from Motorcycle accidents.org
1. Motorcyclists are 35 times more likely to experience a fatal accident compared to cars.
2. Head injury is the leading cause of death in motorcycle accidents
3. More than 50% of motorcycle deaths involve at least one other vehicle.
4. 42% of 2-vehicle motorcycle accidents involve the vehicle turning left while the
motorcycle was going straight, passing, or overtaking the vehicle.
5. Causes of Motor Vehicle Accidents involving a Motorcycle:
a. Weather conditions
b. Lack of turn signal
c. Lane Splitting
d. Ignoring traffic conditions or signals
e. Disobeying speed limits (35% of all motorcycle accidents)
f. Not seeing the motorcyclist or vehicle
g. Driving under the influence of drugs or alcohol
h. Inexperienced driving
i. Negligent Driving
j. Vehicle or road defects
k. Hostile actions
6. Common Injuries
a. Road Rash
b. Broken and dislocated bones
c. Spinal Cord Injuries
d. Traumatic Brain Injuries
e. Death
b. Patient Presentation
i. Surgical Report
1. Patient was involved in a motorcycle accident on 7/23/13.
2. Preoperative diagnosis: Highly comminuted left proximal humeral fracture dislocation
3. Postoperative diagnosis: Highly comminuted left proximal humeral fracture dislocation
4. Operative Procedure: Placement of reverse total shoulder arthroplasty, left shoulder
5. Complications: None
6. Operation Report Notes:

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Rebecca Stevens
Case Study
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7. CT angiogram performed
a. Question in regards to axillary artery thrombosis. Determined to be
compression from fractured humeral shaft during migration. Consulted with
Vascular Surgery team.
8. ORIF declined due to highly comminuted fracture.
9. Additional diagnosis information:
a. Glenohumeral joint dissociation and fracture line extended through the
anatomic neck of the proximal humerus.
b. Deteriorated condition of rotator cuff
10. Surgical Outcome: good condition, no complications, good prognosis.

III.

Physical Therapy Information

a. Evaluation
i. Date of Evaluation: 9/9/13
ii. General Medical History: No significant history prior to accident 7/23/13
iii. Pain: Numeric Rating Scale for prior 24-48 hours: 3-4/10
iv. Falls: no risk of falls, no TUG performed
v. Chief Complaint: injury prevents work and ADLs. Doctor will not release to work until seen at
physical therapy. Discomfort
vi. Functional Scale (1 = unable to perform, 10 able to perform at same level as before injury or
problem)
1. Eating 0
2. Toileting/Grooming 0
3. All Left-Handed activities 0
vii. History of Injury: Motorcycle accident in construction zone. Guy cut him off. Laid bike down
on side and was ejected off the bike into a roll.
viii. Patient Goals: To reach overhead and behind back, return to work
ix. Previous Treatment: PT at another facility post-op
x. Current Symptoms: Left shoulder discomfort. Cold Pack and Moist Heat decrease symptoms.
Nothing stated to increasing symptoms.

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Rebecca Stevens
Case Study
11/14/2013
xi. Measurements
Date
Pain Level
Palpation

IE
3-4/10
Left border
of scapula
WNL

Cervical Screen
SHOULDER
Flexion

GOAL
0-1/10
ttp
WNL

left

right

left

120

170

>
150
>
150

Abduction

170

ER
IR
MMT
Flexion

right

90
T8

NA (surgical protocol)

5/5

Abduction
ER
IR
Supraspinatus
LHB
PROM
Flexion

5/5
5/5
5/5
5/5
5/5

120

Abduction

>
165
>
165

120

ER @
0/45/90
IR @ 0/45/90
ACTIVITIES
Eat
ADLs
L hand activities

4/5
5/5
4/5
5/5
4/5
5/5
4/5
5/5
4/5
5/5
4/5
5/5

10

>
60
>
50

20
0
0
0

10
10
10

xii. Reviewed HEP with patient, goal is HEP independent and compliant
b. Intervention Goals/Surgical Protocol
i. PHASE #1: Post Op Day #1 4 weeks
1. Goals
a. Promote stoft tissue healing
b. Maintain integrity of rTSA
c. Gradual increase of PROM
d. Restore AROM of elbow, wrist, and hand
e. Patient independence with conservative pain control measures through use of
appropriate posture and positioning, cryotherapy, and deep breathing/relaxation
f. Independence ADLs using modification and compensations to maintain
integrity of rTSA
2. Precautions

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Rebecca Stevens
Case Study
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a.

sling to be worn 3-4 weeks post op except during formal PT and HEP
exercises.
b. Avoid hyperextension, anterior capsular stretch, Subscapularis stretch in supine
position
c. No AROM of shoulder except during gentle pendulum
d. No lifting objects with operative arm
e. No flexion beyond 120 degrees when in supine scapular place (begin with 90
degree limit and gradually increase to 120 by week 4)
f. No abduction beyond 90 degrees
g. ER in scapular plane as tolerated respecting soft tissue constraints, typically not
beyond neutral.
ii. PHASE #2: Weeks 4-8
1. PROM
a. Increase to max of 120 degrees forward flexion in supine position
b. Scapular plane abduction to max of 120 degrees as tolerated
c. ER to tissue constraints
d. At 6 weeks, begin gentle IR not to exceed 45 degrees, in scapular plane at 60
degrees
2. AAROM/AROM
a. Forward flexion and elevation in scapular plane in supine with progression to
sit/stand
b. ER/IR in scapular plane in supine with progression to sit/stand
c. Gentle Glenohumeral IR/ER sub max isometrics in 0 degrees rotation and
neutral extension
d. Gentle scapulothoracic rhythmic stabilization and alternating isometrics supine
e. Gentle periscapular and deltoid isotonic strengthening between 6-8 weeks
3. HOME
a. Patient may begin using hand for light ADLs
iii. PHASE #3: Weeks 8-12
1. Continue Phase #2
2. Progress
a. Glenohumeral ER/IR to isotonic strengthening
b. Periscapular and deltoid isotonic strengthening
c. Elbow, wrist, and hand exercises with resistance
d. Joint mobilization
e. AROM/strengthening/activity
f. resisted in flexion and elevation in standing
g. incorporate functional activities to increase ROM and strength
h. cryotherapy, PRN
3. Precautions
a. No lifting above 6lbs
b. No sudden lifting, pushing, or jerking motions
c. Avoid exercise/functional activates that put stress on anterior capsule and
surrounding structures
iv. PHASE $3: 12+ weeks
1. HEP 3-4 times per week
2. Progress strengthening program
3. Return to normal functional activities
4. Return to hobbies within limits by PT and surgeon.
c. Treatment
i. Plan of Care (IE)
1. ROM

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Rebecca Stevens
Case Study
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2. Strengthening
3. Functional Training
4. Modalities
a. Moist Heat 15
b. TENS with MH 15
c. Cold Pack 10
5. Manual Techniques/Joint Mobilization
a. PROM
i. Flexion to 120
ii. ABS scapular plane to 120
iii. ER to tissue constraints
iv. IR to 45 in scapular plane
6. Progressive Home Exercise Program
a. Demonstrated
b. HEP handout provided
c. Patient in agreement
d. No barriers to rehabilitation
7. Other
a. Frequency and Duration of treatment: 3x 12 weeks
b. Aware of diagnosis and prognosis: yes
ii. Reevaluations/Patient Progression
1. To date (11/15/13) patient has returned to work with surgeon restrictions. PT
continues 2-3x week, with continued progressions. Week 16 post op, patient has
returned to full ADLs, with lifting restrictions at end of range and over 20 pounds
overhead.

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Rebecca Stevens
Case Study
11/14/2013
2. Measurements
Date
Pain Level
Palpation
Cervical Screen

IE
3-4/10
Left border
of scapula
WNL

9/27/13
04/10

10/10/13
3/10

WNL

WNL

120

170

80

130

150

170

70

130

130

90
T8

20
hip

30
hip

30
L4

5/5

3/5

4+/5

5/5

3/5

5/5

3/5

5/5

3/5

3+-4/5
3+-4/5
3+-4/5
4-/5

5/5

3/5

4+/5

5/5

3/5

3+-4/5
5/5

120

150

155

161

Abduction

120

120

145

141

ER @
0/45/90

10

60
@90

75

>
60

IR @ 0/45/90

20

70
@60

70
@
90
80
@
60

75

>
50

ER
IR
Supraspinatus
LHB
PROM
Flexion

ACTIVITIES
Eat
ADLs
L hand activities

NA (surgical protocol)

Abduction

0
0
0

5
5
5

iii. Treatment Program

1. Shoulder Flexion AROM
a. Supine Gravity
b. Standing Gravity
c. Standing Yellow
d. Standing Red
e. Standing 1#
f. Standing 2#
g. Standing 3#
2. Scapular Retraction AROM
a. Gravity 20x
b. Standing Red 20x
c. Standing Red 30x

left

right

WNL

left

ER
IR
MMT
Flexion

right

WNL

right

Abduction

left

GOAL
0-1/10
ttp

left

SHOULDER
Flexion

right

10/25/13
4/10

right

>
150
>
150

4/5
5/5
4/5
5/5
4/5
5/5
4/5
5/5
4/5
5/5
4/5
5/5

4+/5
4+/5
4+/5

4+/5

9
8
5

left

>
165
>
165

10
10
8

10
10
10

d. Standing Green 30x

e. Standing Black 30x
3. Biceps AROM
a. Gravity 20x
b. 3# 20x
c. 3# 30x
d. 4# 30x
e. 5kg 30x
4. Physioball Flexion & Scapation
a. 10 x 10
b. 20 x 10

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Rebecca Stevens
Case Study
11/14/2013
5. Pulley Flexion & ABD
a. 2 each
b. 3 each
6. Isometrics ABD, IR, ER
a. 6 x 10 each
b. DC
7. AROM IR/ER
a. 10x
b. 15x
c. 20x
d. 30x side lying
e. 2# 30x - side lying
8. Putty
a. Green 3
b. DC
9. Wrist Flexion & Extension
a. 2# 20x
b. 3# 20x
c. 3# 30x
d. DC
10. Pronation & Supination
a. 2# 20x
b. 3# 20x
c. 3# 30x
d. DC
11. Cane ER & Flexion
a. 10 x 10
b. 2 x 10
c. DC
12. UBE
IV.

13.

14.

15.
16.

a. 120 x 5
b. 90 x 5
c. 60 x 5
Scapation
a. Standing Red 20x
b. Standing Red 30x
c. Standing Green 30x
d. Standing Black 30x
Theraband Flexion, Extension, ER,
IR
a. Standing Red 20x
b. Standing Red 30x
c. Standing Green 30x
d. Standing Black 30x
Prone T
a. 0# 20x
b. 0# 30x
Manual Therapy/Mobilization
a. PROM
i. Flexion on Scapular Plane
ii. ABD
iii. IR
iv. ER
b. MRE
i. Flexion on Scapular Plane
ii. ABD
iii. IR
iv. ER
c. MOBS
i. None

Works Cited
a. OrthoInfo. Reverse Total Shoulder Replacement. American Academy of Orthopaedic Surgeons.
AAOS.org. Available at http://orthoinfo.aaos.org/topic.cfm?topic=A00504. Last reviewed: September
2010
b. Figure 1 A Typical Rotator Cuff Tear MRI. Copyright 2013 Radiological Society of North America,
Inc. (RSNA)
c. Figure 2 A typical follow-up x-ray of a reverse total shoulder replacement. OrthoInfo. Reverse Total
Shoulder Replacement. American Academy of Orthopaedic Surgeons. AAOS.org. Available at
http://orthoinfo.aaos.org/topic.cfm?topic=A00504. Last reviewed: September 2010
d. Motorcycleaccident.org . Motorcycle Accident Statistics and Possible Causes. Available at:
http://www.motorcycleaccident.org/motorcycle-accidents-statistics-and-possible-causes/

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