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Annals of Sports Medicine and Research

Case Report

Rehabilitation Following Fibro

Adenoma Removal Surgery for
a Female Junior Elite Basketball
Player with Sacroiliac and
Lumbo pelvic Dysfunction: A
Case Report

*Corresponding author
Indy MK Ho, Sports Therapy Centre, Technological and
Higher Education Institute of Hong Kong, Hong Kong;
Tel: 852-9821-8161; Email:
Submitted: 01 March 2015
Accepted: 18 March 2015
Published: 19 March 2015
Copyright
2015 Ho et al.
OPEN ACCESS

Keywords
Multifidus
Lower back pain
Core stability
Exercise therapy
Instability

Edith YT Lam, Kitty TK Wong and Indy MK Ho*

Sports Therapy Centre, Technological and Higher Education Institute of Hong Kong,
Hong Kong

Abstract
Introduction: Fibro adenomas is the most common benign breast tumors in young
women while15% of the population with lower back and buttock pain was caused by
the sacroiliac joint dysfunction. This is the first reported case of the rehabilitation of
fibro adenoma removal surgery for an elite female basketball player with suspected
lumbo pelvic instability and sacroiliac joint dysfunction.
Case presentation: A 17-year-old female basketball player had fibro adenoma
excision on her left breast and presented with pain in palpation or left shoulder
movements. She presented with two years history of lower back pain in subsequent
visits that was worsened in trunk flexion or rotation.
Daily application of sports massage on chest scar tissues and gentle shoulder and
scapula mobilization were applied. Besides, deep core muscles activation, postural
control training and upper limb muscle strengthening exercises were introduced. After
1-week rehabilitation, significant reduction of chest pain with shoulder movements
was achieved. The patient could also activate the lumbar multifidi and perform some
advanced core stability exercises with satisfactory core control.
However, she was urgently called back for resuming normal sport training and
was resent for rehabilitation again due to the deterioration on her chest wound and
lower back pain after having basketball practice and conditioning for one day. Pain
was well controlled after resuming rehabilitation with the use of pelvic binder.
Conclusion: Negative result was obtained due to early return to practice with
incomplete rehabilitation. The judgment on making progression and return to practice
is critical.

ABBREVIATIONS
SIJ: Sacroiliac Joint; ROM: Range Of Motion; LBP: Lower Back
Pain; NRS: Numerical Rating Scale; ASIS: Anterior Superior Iliac
Spine; PSIS: Posterior Superior Iliac Spine

INTRODUCTION

Fibro adenoma is the most common benign breast tumor

in young women [1-2]. Traditional surgery for removing tumor
resulted in large wound in the skeletal muscles, causing pain,

inflammatory response and scar tissue. It may limit the range

of movement (ROM) [3]. To the best of our knowledge, there is
no previous publication on the rehabilitation of fibro adenoma
removal surgery for female elite basketball players. Up to 15%
of the population has lower back and buttock pain caused by the
sacroiliac joint (SIJ) dysfunction [4-5] and it can also produce
pain along the same distribution as the sciatica [4]. It may be due
to the weakness of the deep abdominal, gluteal and core muscles
which are critical in holding the correct pelvic position and
preventing SIJ hyper mobility [5].

Cite this article: Lam EYT, Wong KTK, Ho IMK (2015) Rehabilitation Following Fibro Adenoma Removal Surgery for a Female Junior Elite Basketball Player
with Sacroiliac and Lumbo pelvic Dysfunction: A Case Report. Ann Sports Med Res 2(2): 1019.

Ho et al. (2015)
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CASE PRESENTATION
A 17-year-old Chinese national junior female basketball
player playing the forward position received a fibro adenoma
removal surgery at her left breast two weeks before she was
seen by the rehabilitation training center. During the initial
assessment, she complained severe pain on the left chest (Figure
1) with a one inch long observable dark red scar. Despite this, in
subsequent visits the patient presented with two years history of
lower back pain (LBP) especially worsened during trunk flexion
and rotation. Symptoms were aggravated by prolonged sitting
or standing up from sitting position but eased in lying position.
Apart from these, previous history of ankle sprain was also noted.

Upon physical examination, the patient presented with

winged scapular and round shoulder from our observation and
she demonstrated decreased awareness in maintaining correct
spinal posture. Severe tenderness rated as 7/10 pain level in
Numerical Rating Scale (NRS) [6] was observed upon light touch
or palpation on her wound. Adhesions, thickenings and nodules
were found surrounding the wound. Our patient reported
pain free in resting or throughout active shoulder flexion and
extension. However ROM of most other left shoulder movements
were restricted by the pain on the chest wound. She complained
severe pain (rated 7/10) in performing active left shoulder
horizontal abduction which restricted her from reaching the outer
range and moderate pain (rated 4/10) in passive left shoulder
horizontal abduction. Significant pain during 100 degrees of
abduction was noted. Slight pain (rated 1/10) was also reported
in active left shoulder diagonal abduction, external rotation as
well as performing left hand behind back. Besides, the pain did
not subside immediately once aggravated. For the special test,
the patient was able to perform wall push up without pain. Lower
limb functional test including squat, single leg standing and
walking were performed without pain. Due to the high irritability
and early stage of tissue healing of our patient, we decided not to
perform any other muscle strength or functional test on upper
limb. We concluded the incomplete healing of scar tissue with
adhesions on the muscle fibers of pectoralis major as our initial
clinical impression.

Figure 1 Painful site of our patient.

Ann Sports Med Res 2(2): 1019 (2015)

Despite the chest pain, our patient also complained deep

dull pain on the left SIJ when performing trunk flexion during
subsequent visits. Lowered anterior superior iliac spine (ASIS)
and elevated posterior superior iliac spine (PSIS) of the left
pelvis was observed. Our patient felt pain in performing spinal
flexion, extension and rotation especially during extreme range
of flexion and extension with overpressure. Apart from the
abnormal pelvic position observed, special tests on the SIJ were
conducted. Positive results with the increase of deep dull aching
pain localized to the posterior iliac crest and the SIJ during the
Faber test, sacrum distraction test and sacrum thrust test were
obtained [7-8]. Spastic erector spinae at the lower thoracic and
lumbar region associated with the SIJ and LBP was observed, and
the recruitment of Multifidus muscles was not felt by palpation.
Applying central and unilateral posterior-anterior accessory
movement on multiple levels of lumbar spine produced significant
comparable pain. Since no neurological sign and symptom was
reported, we have ruled out the possibility of nerve compression
or neural involvement. In performing single leg extension in
prone lying, a significant slower activation time of gluteus maxim
us than the erector spinae and hamstring muscles was observed
through palpation. Based on the pain pattern, aggravating and
easing positions, standing posture and the results from the
special tests on SIJ, our initial clinical impression to her problem
was anterior in nominate rotation of left pelvis with suspected
lumbar and SIJ instability. We immediately prescribed passive
mobilization to correct the anterior in nominate. Although normal
ASIS and PSIS levels were restored after the quick treatment and
confirmed in our reassessment, only slight decrease on SIJ pain
was reported.
Based on the timeline of tissue healing (2 weeks postoperation) and the signs and symptoms, our treatment goals
and rehabilitation plan decided were to promote better wound
healing and pain control in the chest, enhance the lumbo pelvic
and SIJ stability by reactivation of relevant stabilizers as well
as prevention of reconditioning after prolonged detraining. The
rehabilitation program was composed of two parts including the
sports therapy and muscle strengthening. The sports therapy
included daily application of gentle and pain free sports massage
such as effleurage, palm kneading and cross-fiber friction (Figure
2) on the surrounding muscles and scar tissues located for 20
minutes. Passive static stretching (Figure 3) with pain free for
20-30 seconds with 3 repetitions on the pectoral region and
gentle shoulder and scapula mobilization with pain free were
performed after the sports massage. Besides, deep core muscles
and activation, including the transverses abdominis (Figure
4) and multifidi (Figure 5) as well as postural control training
(Figure 6) were also performed on the daily basis as well.
Despite the sports therapy treatments, progressive muscle
strengthening exercises with light or even no resistance on the
upper limb muscles in pain free position were introduced. Our
patient experienced slight pain in performing certain upper limb
resistance exercises such as dumbbell front shoulder raise and
dumbbell biceps curl (rated 1/10). Moderate pain was reported
after the completion of 6 repetitions of wall push up (rated
6/10) and during the eccentric phase of shoulder raise in full

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Figure 2 The demonstration of sports massage by simulation (The real patient is not shown): A effleurage. B palm kneading. C cross-fiber
friction.

Figure 3 The demonstration of passive pectoral stretching by simulation (The real patient is not shown).

Figure 4 The demonstration of transverses abdominis activation with draw-in maneuver and finger tips palpation by simulation (The real patient
is not shown): A starting with inhalation. B finishing with exhalation.

can position (rated 6/10). All these exercises were modified or

removed immediately if pain was reported to assure training
without pain.

After the completion of 1-week rehabilitation, significant

reduction of chest pain during shoulder movement was observed
Ann Sports Med Res 2(2): 1019 (2015)

(Figure 7). Our patient was also able to activate the lumbar
multifidi with the facilitation from the finger tips palpation of
the therapist and she was able to perform some advanced core
stability exercises with satisfactory core control, including
maintaining neutral spine and significant activation of gluteus

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Figure 5 The demonstration of multifidi activation with draw-in maneuver and finger tips palpation by simulation (The real patient is not shown):
A starting with inhalation. B finishing with exhalation.

Figure 6 The demonstration of postural training with concurrent multifidi activation and draw-in maneuver incorporated by simulation (The real
patient is not shown): A Anti-flexion. B Anti-extension. C Anti-rotation.

Pain level on the chest wound in different active

left shoulder movements

9
8

5
4

5
4

0
1/9/2015

1/8/2015

1/7/2015

1/6/2015

1/2/2015

1/1/2015

12/31/2014

Numeric Rating Scale for Pain

10

0
1/12/2015

1/11/2015

Date

Horizontal
abdcution
Date
External rotation

1/10/2015

1/5/2015

1/4/2015

Circumduction

1/3/2015

Palpation

Flexion and extension

Diagonal abductioin

Figure 7 The progress on the chest pain level in different left shoulder movements (The player was called back for resuming basketball training on
7January).
Ann Sports Med Res 2(2): 1019 (2015)

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maximus with palpation, such as quadruped with single hip
extension.

After the 1-week rehabilitation, our patient was urgently

called back by the coaching team for resuming normal basketball
and high intensity conditioning without the consultation from
rehabilitation and training center. She immediately reported the
leakage of fluid from her chest wound after performing several
dribbling drills and heavy barbell bent over row strengthening
exercise. Despite the re-injury of the chest wound, her LBP and
SIJ pain was exacerbated after performing basketball drills and
trunk rotation exercise with weight plate. She was then resent
to the rehabilitation training center the day after returning to
practice. After the reassessment, she reported moderate chest
pain again (rated 5/10) and resting pain on lumbar region and
SIJ. The LBP was increased to moderately high level (rated 6/10)
when performing trunk flexion. We resumed the rehabilitation
on the chest, lower back and SIJ as before but the extreme LBP
and SIJ pain were reported in performing single leg bridging
exercise, which was well performed and tolerated before return
to basketball practice. Due to such deterioration and unstable
condition of the lower back and SIJ pain after resent for redoing
the rehabilitation, we advised her putting on a pelvic binder
during and after exercise. Since then, she reported pain free in
most movements and daily activities, and was able to resume
most core stability exercises in pain free condition with the pelvic
binder.

and erector spinae contributing to lumbo pelvic and SIJ instability

should also be corrected as part of the exercise rehabilitation.
Although there was no direct causal relationship between the
chest surgery and the lumbo pelvic or SIJ dysfunction in our case,
precautions in exercise selection for both the chest and lower
back were made because of the increase of pain on chest wound
in certain movements and positions. For example, exercises with
excessive weight bearing on chest such as plank and stability
training in prone lying position or any exercise with excessive
shoulder horizontal abduction resulting in more pain were not
considered. On the other hand, single arm upper limb exercises on
the good side which have long lever arm and potentially increase
trunk rotation such as dumbbell chest press or fly should also be
avoided especially when the lumbar spine or SIJ was unstable. As
the decision on early return to practice without the agreement
from medical or rehabilitation professionals have put our case
in a more vulnerable position and finally led to the deterioration.
Therefore a strict return to play or practice criteria and mutual
agreement between coaching and medical teams before resuming
the normal practice was recommended.

To conclude, the proper design of rehabilitation program

for our patient with fibro adenoma removal operation and
suspected lumbo pelvic and SIJ dysfunction is challenging due
to the high irritability and poor neuromuscular control. The
accurate judgment on when the training progression and return
to practice should be permitted is difficult but critical.

DISCUSSION

REFERENCES

There is no case report in the literature that documents the

sports therapy and exercise rehabilitation after fibro adenoma
removal surgery and for SIJ pain most literature only focused
on the assessments, diagnosis and causing factors. In our case,
the patient reported pain decrease after gentle sports massage
around the chest wound, passive shoulder mobilization and
pectoral stretching, and light resistance training in pain free
position. All these were proposed to promote better realignment
and remodeling of the scar tissues, and breakdown of adhesion
and fibrosis which are in line with similar findings from previous
studies as well [9-11]. The positive result in pain reduction on
SIJ and lumbar after the core muscles activation, including the
multifidi, transverses abdominis and gluteus maximus, and
stability training was apparent and consistent to finding or
recommendation from literature [12-15]. The application of
pelvic binder for relieving LBP and SIJ pain has been described
before [16-17] and the positive feedback from our case was
apparent as well. Another key to symptomatic improvement
in the early stage of our case before returning to practice was
avoiding risky exercises, such as trunk rotation, explosive moves
and high impact asymmetric lower limb weight bearing exercises
that may put extra stress on the unstable lumbo pelvic structures
and SIJ. Therefore, the sequence of progressive rehabilitation on
lumbo pelvic or SIJ instability should be the activation of deep
local stabilizers without loading first followed by progressive core
stability exercises. The strength training with high resistance as
well as functional sport specific moves should only be performed
in pain free after satisfactory core control has been achieved.
Moreover, the poor muscle recruitment pattern that weak and
slow gluteal muscles with synergistic dominant on hamstring

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Cite this article

Lam EYT, Wong KTK, Ho IMK (2015) Rehabilitation Following Fibro Adenoma Removal Surgery for a Female Junior Elite Basketball Player with Sacroiliac and
Lumbo pelvic Dysfunction: A Case Report. Ann Sports Med Res 2(2): 1019.

Ann Sports Med Res 2(2): 1019 (2015)

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