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Case Reports |
R Burks, PT, MPT, CHT, is Clinical Instructor, School of Biokinesiology and Physical Therapy, University of Southern California, and Physical Therapist, USC University Hospital
W Burke, PT, DPT, OCS, is Assistant Professor of Clinical Research, Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, and Department of Biokinesiology and Physical Therapy, University of Southern California
M Stevanovic, MD, PhD, is Professor of Orthopedic Surgery, Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California
(rburks{at}usc.edu). Address all correspondence to Mr Burks at USC University Hospital, 1520 San Pablo, Suite 2200, Los Angeles, CA 90033 (USA) The manuscript was written in partial completion of requirements for the Post-Professional Doctorate of Physical Therapy at the University of Southern California
Submitted February 26, 2005;
Accepted September 19, 2005
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Outcomes. Latissimus dorsi muscle isometric force generation on the injured side was 92% of that of the uninjured side. The patient returned to work as a SWAT team member.
Discussion. No detailed reports of postoperative latissimus dorsi tendon rehabilitation are available. The program for this patient was based on research demonstrating the timeline for recovery of tensile strength in healing tendons. This approach can direct rehabilitation following repair of other tendons, especially in uncommon injuries where specific guidelines have not been developed. [Burks R, Burke W, Stevanovic M. Rehabilitation following repair of a torn latissimus dorsi tendon.
Key Words: Clinical decision making • Evidence-based practice • Guidelines • Rehabilitation • Rupture • Shoulder • Tendon injuries
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 TopAbstract Introduction Case DescriptionInterventionOutcomeDiscussionAppendixReferences |
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The goals of rehabilitation following tendon reconstruction are to restore motion and strength (muscle force-generating capacity) without subjecting the healing tissue to excessive forces that may hinder healing or rupture the repair.6 One of the most important clinical considerations is how quickly to advance the patient’s program and in what manner, for instance by increasing resistance, range of motion (ROM), or repetitions. Intervention should be guided by knowledge of the physiology of healing, especially as it influences tissue tensile strength.7
Tendon healing progresses through the same overlapping phases as other tissues: inflammation, proliferation, and remodeling.8 During the inflammatory phase, the first 3 to 5 days following injury or surgery, phagocytic cells remove devitalized and damaged tissue. Chemicals are released that stimulate fibroblast activity, initiating the transition to the proliferative phase. This second stage can begin as early as 48 hours following injury and can last 6 to 8 weeks. New blood vessels form in the wound to enhance delivery of nutrients to the healing tissue. Fibroblasts multiply and produce new extracellular matrix and collagen. This immature collagen is randomly oriented and has limited strength. The third stage, the remodeling phase, overlaps the latter portion of the proliferative phase and continues for several months. Throughout this phase, collagen gradually becomes oriented along lines of stress, and its structure becomes organized to provide increasing resistance to stretch and tearing.9
Mason and Allen7 examined the tensile strength of healing flexor carpi ulnaris and extensor carpi radialis tendons in dogs. Following surgery, the involved limb was: (1) immobilized to prevent tensile force on the repair for the duration of the experiment (35 days), (2) immobilized for 21 days, then allowed unrestricted motion, or (3) immobilized for 1 week, then allowed flexion but not extension, which subjected tendons to tensile forces from muscle contraction but not from passive lengthening. The authors found that in the first 3 to 5 days after surgery, tensile strength at the site of laceration, as well as the ability of the tendon to hold sutures, decreased 50% to 75% from the strength immediately following repair. The tensile strength then began a rapid increase, but was not consistently greater than the immediate post-repair strength until 14 days following surgery. Strength continued to increase until day 16 and then reached a plateau. During this period, Mason and Allen observed that progression through the phases of healing and the resulting increase in tensile strength were unaffected by whether or not the limb was immobilized with the tendon slack. Unprotected tendons, however, were much more likely to rupture, due to increased tensile forces with use, than were immobilized tendons.
A second phase of improvement in tensile strength began between days 19 and 21. From this point until the end of the experiment (day 35), tendons in dogs that were allowed active motion (unrestricted motion or flexion only) developed strength much more rapidly than in dogs with immobilized tendons. The authors noted that the period of initial loss of strength appeared to correspond to the "phase of exudation and fibrous union" (inflammatory phase), the first period of strengthening corresponds to the "phase of fibroplasia" (proliferative phase), and the second strengthening period to the "phase of maturation or organizing differentiation" (remodeling).7(p454) Based on their findings, Mason and Allen7 recommended that, in the clinical setting, repaired tendons be immobilized for 2 weeks and then allowed "restricted" use for 1 to 2 weeks. Beyond this time, they suggested that "active use" could be initiated.
Hirsch10 examined tensile strength in intact peroneus brevis tendons in the rabbit, as well as in tendons that had undergone surgical repair following a laceration. The force required to rupture an intact tendon was found to be about 3 times the maximum force generated by the muscle. Hirsch noted that this force provides a large safety margin, making rupture of healthy tendons unlikely in conventional activities.
For the first 8 weeks following surgery (early remodeling phase), Hirsch10 found that the force required to rupture a lacerated and repaired tendon was less than the force generated by a maximum muscle contraction. At 24 weeks following surgery, the tensile strength of lacerated and repaired tendons was only 50% of that of healthy intact tendon. These findings suggest that maximum muscle contraction forces should be avoided for at least 8 weeks following tendon repair and that significant tendon weakness exists for a considerable period thereafter. Hirsch performed muscle releases on all of the lacerated and repaired tendons due to the inability to immobilize the limbs in such a way as to prevent excessive force on the repair. He therefore could study only the rate of increasing tensile strength in the absence of tensile stresses.
Gelberman et al11 compared the tensile strength of healing canine flexor tendons that were either immobilized following repair or subjected to passive tensile stresses early or late in the healing process. The flexor tendons of dogs in the control group were immobilized for the duration of the experiment. In the first experimental group, early passive mobilization exercises began immediately following tendon laceration and repair. In the second experimental group, delayed passive mobilization exercises began 3 weeks following repair. Passive mobilization in both groups was performed for 5 minutes daily.
The researchers11 found that, 3 weeks following surgery, the tendons in the early mobilization group withstood a tensile load twice that of the other 2 groups. At 12 weeks after repair, the tendons in the early mobilization group ruptured at tensile forces almost 50% as high as the tensile forces on undamaged tendons; the tendons in the delayed mobilization group ruptured at 33% and the immobilized tendons ruptured at only 20% of the tensile force required for rupture of undamaged tendons. Gelberman et al recommended initiating carefully controlled passive mobilization of repaired tendons soon after the surgery.
Enwemeka et al12 examined the effects of early active mobilization of tensile strength in healing tendon. In a rat model, lacerated and repaired Achilles tendons allowed unrestricted active motion following 5 days of casting had increased tensile strength at 8 days after repair compared with tendons immobilized for the full 8-day period or with tendons allowed active motion from the second day to the fifth day following repair. They also found increased incidence of rupture in both the immobilized tendons and the tendons allowed active motion at day 2. The authors interpreted their data as showing that active motion was important in enhancing tensile strength of repairs, but that this effect occurred only if the motion was allowed too early in the healing process. This finding is consistent with those of Mason and Allen.7 Enwemeka et al emphasized that the rate of healing in rats is much faster than in humans, but the progression through the phases of healing is similar.
Direct studies of tensile strength of healing tendons in humans are not possible due to ethical considerations. However, tensile strength can be inferred by comparing rates of rupture between experimental groups. In a study of recovery following finger flexor tendon lacerations in humans, early passive mobilization (following up to 5 days of immobilization) improved final active range of motion (AROM) compared with immobilization for 3 1/2 weeks, without increasing incidence of tendon rupture.13 Because of these results, early controlled passive mobilization has become a cornerstone of successful flexor tendon injury rehabilitation programs.14
Traditionally, Achilles tendon ruptures have been casted for 4 to 9 weeks following surgical repair to prevent rerupture.15 Two prospective, randomized clinical studies16,17 compared immobilization with an early mobilization protocol following Achilles tendon repair. The findings of these 2 studies16,17 suggest that, in Achilles tendon repairs, early mobilization does not significantly change tensile strength of repairs in comparison with immobilization.
The implications of basic science findings on tendon healing for design of a rehabilitation program can be summarized as follows. During the inflammatory phase of healing, 3 to 5 days following injury or surgery, tendon tensile strength and ability to hold sutures are at their lowest levels. During this time, protected rest is recommended. Following this period of rest, a program subjecting the healing tendon to gradually increasing tensile forces should be initiated. Progression of the program should be incremental and slow to allow and promote collagen proliferation, maturation, and fiber alignment.
During the proliferative phase, 5 to 28 days after injury, controlled passive movement should be initiated, keeping the repaired tendon in a protected position to avoid excessive tensile forces. The allowed passive range of motion (PROM) can be gradually increased as healing progresses. As the tissue moves into the remodeling phase of healing (4–8 weeks following injury), the tendon begins to be able to tolerate the level of force generated by active muscle contraction. Active motion should begin with an exercise progression designed to increase tensile force in a controlled manner. Initially, active movement in gravity-eliminated positions will prevent excessive resistance due to the weight of the limb; gradual increases in the muscle force generated may be achieved through increased antigravity movement as the repair becomes stronger. External resistance to the involved tendon (eg, weights, elastic cord) should be avoided until 8 weeks following surgery, with the resistance increased incrementally after that time. At 12 weeks following surgery, the tendon repair should be able to withstand the full force of muscle contraction without rupture.
Rupture of the tendon of the latissimus dorsi (LD) muscle appears to be uncommon. Only 4 previous case reports of spontaneous rupture of the LD tendon have been reported in the English-language literature (Tab. 1).18–21 The outcomes of both surgical and nonsurgical management were good. These cases briefly mentioned rehabilitation following surgery, but they provided little specific information about the intervention are given. Our literature search found no detailed reports of rehabilitation following an LD tendon rupture or repair.
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Due to its large size and good vascularity, the LD muscle is a common source of free flaps for repair of major soft tissue defects. Laitung and Peck24 and Fraulin et al25 studied function following LD transfer or free flap graft and found little residual disability.
The purposes of this case report are to document the rehabilitation of a patient following LD tendon repair and to present the scientific rationale for the treatment approach.
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Surgery
The patient underwent exploration and direct repair of the ruptured conjoined LD and TM tendon approximately 4 weeks following injury. Two bone anchors secured the tendon to the insertion site on the humerus. Following surgery, the arm was placed in a shoulder immobilizer for 1 week. The surgeon instructed the patient to perform pendulum exercises starting 1 week following surgery to prevent glenohumeral joint adhesions, but limited abduction to minimize tensile stress to the repair. Six weeks after surgery, the patient was referred for physical therapy.
Initial Physical Therapy Examination (6 Weeks Following Repair)
A review of the patient’s previous medical history revealed no other relevant health problems. The patient did not smoke or drink significant amounts of alcohol. He stated goals of returning to work and recreational participation in rodeo team and calf roping events. Returning to work as a SWAT team member would require passing a physical examination that included performing 5 pull-ups.
The patient initially reported no pain at rest and 1–2/10 pain (on a verbal numerical scale defined as 0="no pain" and 10="the worst pain you can imagine") with the pendulum exercises. Pain with active movement during the evaluation increased near the end of the available flexion and abduction to about 5/10. The examiner had instructed the patient not to attempt or allow movements that created pain in excess of 5/10 to limit risk of rupturing the tendon repair. Thus, pain was the factor limiting motion.
Examination.
The patient was noted to have an incision scar in the axilla approximately 9 cm in length, running approximately in the sagittal plane. The wound was fully closed and had no signs of infection. There was mild scar hypertrophy and tenderness to palpation in the area around the scar. The skin at the scar adherent to the underlying tissue layers creating a moderate limitation in skin gliding. Pain at the end of the available AROM and PROM seemed to coincide with tension in the scar.
Measurements of the patient’s shoulder ROM are shown in Table 2. Passive range of motion was limited by pain. Goniometric measurements of the upper extremity have been found to have an intrarater standard deviation of 0.8 degree and reliability (r) of .89.26 Joint play was not found to be limited. Scapulohumeral rhythm was grossly normal for flexion and abduction within the available ROM. Posture was normal. Range of motion at the elbow, forearm, wrist, and hand appeared to be within normal limits as assessed by visual observation.
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.98.28 The authors did not test LD and TM muscle strength (internal rotation, extension from a flexed position, adduction) to prevent strain to the recent tendon repair. The identified minor weakness in the left upper extremity was attributed to 10 weeks of disuse (preoperatively and postoperatively) due to injury.
Evaluation.
The patient initially reported pain at a level 3/10. Range of motion was good (PROM was 66% of normal, limited by pain) for the current stage of healing; based on prior clinical experience, it was thought that achieving full ROM would not be difficult. Range-of-motion limitations noted initially appeared to be due to scar adhesions and resulting pain rather than to capsular restrictions. Only mild strength limitations were noted in the manual muscle tests; however, the patient would need a high degree of strength to return to work and recreational activities safely. Furthermore, although manual muscle testing was not performed for the LD and TM muscles at the time of the examination due to concerns about tensile strength of the repair, limitations in these muscles were anticipated because of injury and surgery. Therefore, strengthening was chosen as the major goal of treatment, with a secondary emphasis on ROM. Scar mobilization was not chosen as an initial intervention, but was considered as an option later if adhesions did not resolve with movement and muscle contraction.
As noted above, the literature provides a great deal of useful general information to assist with the development of a timeline for exercise progression following tendon repair. However, although specific programs are described for a variety of other tendons, no program for the LD tendon was available. A plan of care was designed to advance exercises gradually without risk of rupture or reinjury. Table 3 provides a summary of the principles guiding the plan progression.
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During the examination, the patient expressed frustration with his postsurgical activity restrictions. Early in the intervention progression, he began a vigorous strengthening program for muscles of the forearm, wrist, and hand in positions that protected the LD tendon repair (Appendix). This distal strengthening program was important for several reasons. For this patient, strengthening and reconditioning the muscles controlling the more distal joints in the arm and hand was important for functional return. Strengthening could be done in these areas without endangering the repair. Moreover, this early program seemed to satisfy the patient’s wish for vigorous rehabilitation, thus decreasing his frustrations with his activity restrictions while respecting the limitations of the healing tissue. The program was performed on the BTE Work Simulator II,* which provides good isolation of the targeted muscles (Fig. 1). The precise positioning allowed with this equipment protected the LD muscle from being used to stabilize the shoulder during distal upper-extremity exercises.
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Manually resisted scapular protraction, retraction, and elevation were begun with the patient in a side-lying position. Manual resistance was chosen for these movements to ensure that the therapist could monitor and prevent LD muscle substitution. Resisted scapular depression was avoided at this time because this movement would probably have been accomplished through LD muscle contraction (via the humerus).
By the end of week 8, the patient had full active pain-free shoulder flexion. The absence of pain suggested that the tendon repair was able to withstand passive tensile forces in that plane of motion. Range of motion in other directions was improving and pain was resolving at the ends of ROM.
Postoperative Weeks 9 Through 12
Exercises that would use the LD muscle with very light resistance were added (eg, shoulder extension from a flexed position with the elbow extended using light elastic band resistance). As a general rule, resistance or ROM in a specific exercise was increased only if it did not produce pain. New exercises were attempted cautiously and were allowed only if they did not cause pain. Exercise on an isokinetic Upper Body Ergometer
was begun. This machine allows selection of various speeds with the mechanism providing sufficient resistance to prevent exceeding that speed. A high speed (120 rotations per minute) was chosen initially to limit torque-generating potential to protect the LD tendon. The speed was gradually decreased through this period, progressively increasing the resistance and tensile forces generated.
Active range of motion was improving in all directions except internal rotation, which was noted to be 50 degrees (decreased from 65° initially). Gentle manual stretching for this movement was added, and internal rotation improved.
Resistance or duration was increased for all exercises, but only one parameter was increased in a single visit. By week 12, strength throughout the forearm, wrist and hand was 5/5. With the goal of 5/5 strength in these areas met, BTE strengthening for the lower arm was discontinued. Shoulder strength was 5/5 for flexion, abduction and external rotation. Internal rotation was 4+/5, and adduction and extension from 90 degrees of flexion or abduction was 4/5, at least partially limited by pain in the axilla.
During week 10, without consulting with the physical therapist or physician, the patient attempted to do a pull-up at home. He reported being unable to do more than hang from his arms due to pain in the left axilla. Although there was no lingering pain or loss of strength or ROM following this incident, the patient was cautioned that he risked rupturing the repair by putting too much force on the tendon too soon.
During week 11, the patient requested permission to attempt a pull-up again. Following consultation with the surgeon, it was suggested that the patient wait another 2 weeks to ensure adequate healing.
During week 12, the patient began to report pain along the incision in the axilla at the end of flexion and abduction range with LD muscle concentric/eccentric resistance activities such as pulling elastic cords, weighted pulleys, or closed kinetic chain vertical push-pull exercises direction on the BTE Work Simulator II (Fig. 2). There was no change in palpation findings from the initial evaluation. It was thought that the pain was due to increased mechanical stress on the scar due to combined tensile forces due to passive stretch and active contraction. These exercises were limited to pain-free ROM and resistance, and manual scar mobilization in the axilla was added. The pain decreased but recurred intermittently. Exercise progression for all other exercises continued, as there was no pain with these activities.
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Total Gym
pull-ups were added as a way to simulate the pull-up motion with less than body-weight resistance (Fig. 3). The patient found even this exercise painful if performed to full ROM. The choice was made to avoid end-range shoulder flexion and maintain a relatively high level of resistance. However, it might have been possible for the patient to exercise at full ROM if the resistance had been sufficiently decreased.
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During week 16, the patient was able to complete 5 pull-ups despite 3–4/10 pain on the last 2 repetitions. He reported no pain while exercising on the Total Gym at full ROM at level 10 (33% of body weight).
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TopAbstractIntroductionCase DescriptionInterventionOutcomeDiscussionAppendixReferences |
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Much of the literature on tendon healing in humans involves Achilles tendon injuries and flexor tendon injuries in the hand. Over the last 25 years, many recommended treatment progressions have been developed for flexor tendons.14 All of them are based on the basic science of tendon healing, as was the treatment plan for the current patient. One difference between flexor tendon treatment guidelines and the current case is the rationale for early mobilization. Flexor tendons tend to develop adhesions between the repaired area and the scar in the surrounding tissue.31 These adhesions limit tendon gliding, resulting in loss of ROM, strength, and function. Flexor tendon treatment programs attempt to mobilize the tendons as soon as possible to minimize these adhesions. In rehabilitation after LD tendon repair, especially after an avulsion injury at the bony insertion where little tendon gliding occurs, adhesion at the repair site represents less of a potential problem for ROM. (We believe that pain experienced by our patient was due to stretching of the scar and surrounding soft tissue with glenohumeral movement, not due to limited tendon gliding.) Moreover, the structures surrounding the LD tendon are more robust than structures in the hand, making for easier mobilization of scar tissue manually or through exercise should adhesions develop. Pendulum exercises were used during the early healing phases to attempt to maintain glenohumeral joint mobility without putting too much tensile stress on the repaired tendon. These exercises were not intended to enhance tendon mobility.
Personality factors in this patient also guided aspects of the plan of care. The patient was anxious to return to normal activity as soon as possible. Despite careful explanation of the need to allow sufficient time for tissue healing, the patient expressed reservations about the plan of care and a desire to progress more rapidly. Early components of the plan included vigorous strengthening of the biceps brachii muscle and the forearm, wrist, and hand muscles. This presented little risk of causing LD tendon rupture but served, in part, to satisfy the patient’s zeal to initiate vigorous exercise. Even so, the patient attempted a pull-up at post-operative week 10, earlier than was prudent. Fortunately, he escaped injury.
Healing tendons are subjected to 2 kinds of tensile forces: active forces produced by contraction of the involved muscle and passive forces produced by body movements that place the muscle in a lengthened position. For the LD, the body movements that produce passive lengthening include shoulder abduction, flexion, and external rotation. In the upright body position, moving into these stretched positions is accomplished with the LD muscle relaxed due to reciprocal inhibition of antagonist muscles. We thought that resistance exercises with weights would be relatively safe when performed in the upright position, so these exercises were used early in the treatment progression.
The patient was a young man in good health who did not smoke. Had he been elderly, a tobacco user, or had other health factors that might slow healing such as diabetes or use of corticosteroids, the treatment progression would have been slower. It would probably not have been advisable to prolong the immobilization and delay the initiation of therapy due to the increasing likelihood of loss of glenohumeral motion. A slower treatment progression should provide the benefits for healing of motion and gradually increasing stress in a context of careful control.
In reviewing this case, we noted some possible areas for improvement of the plan of care. It might have been possible to initiate increasing AROM or PROM earlier than 6 weeks following repair, although this patient’s personality suggested that he would have been likely to exceed whatever limitations he was given, and therefore risk rerupture. The clinic lacked equipment to allow pull-ups or progression to body weight resistance in the near–end-range flexion or abduction positions. Dips in the parallel bars might have been a useful exercise, easily progressed based on the amount of lower-extremity assistance used. Placing a weight scale under the patient’s feet during the exercise could have monitored the amount of force on the LD tendon.
When developing an exercise program, therapists must integrate a number of factors to develop an intervention plan that is appropriate for the patient and consistent with anatomical and biomechanical considerations. These factors include physiological information regarding the healing process and the effect this process has on tissue tensile strength; patient demographic, health, and psychological factors; and an understanding of the mechanical forces generated in the involved tissues by specific exercises. Consultation with the referring physician also should guide the time frame for exercise progression.
The low incidence of LD tendon tears will make future research specific to this injury difficult. Randomized controlled trials are needed to further explore the timing of exercise program progression following repairs of more frequently injured tendons. The effect of factors such as the amount of tendon gliding needed at the repair site, and patient age and health, on the rate of exercise progression needs to be clarified. The utility of pain as a marker for excessive tissue strain also warrants further exploration.
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| Footnotes |
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* BTE Technologies Inc, 7455-L New Ridge Rd, Hanover, MD 21076. 
Cybex International Inc, 10 Trotter Dr, Medway, MA 02053. (Cybex Upper Body Ergometer no longer manufactured.)
Engineering Fitness International Inc, 7755 Arjons Dr, San Diego, CA 92126.
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