Patient Case Study – Full Rotator Cuff Avulsion Rehabilitation

March 29, 2021

Patient details: 65yr old male, Obese, Hypertension, no other comorbidities

Occupation: Heavy haulage truck driver

Injury Details: Fell between two truck trailers onto the right arm causing major rotator cuff tearing. Right shoulder arthroscopic subacromial decompression, excision of the AC joint and open repair of a massive avulsion of the entire rotator cuff on the 24/08/2020.

Critical Physical Demands of the job role: Ingress/Egress from large trucks and heavy machinery requiring 3 points of contact and ladder climbing. Lifting to 30kg from floor to shoulder height, forceful manoeuvring of items weighing up to 30kg at chest height, occasional heavy lifting above head height up to 30kg, repetitive upper limb use when tying downloads. Physical tasks can be completed for periods of up to 4 hours on a repetitive basis.

Rehab Timeline: The patient commenced physiotherapy immediately post-op and completed this for the first 6-weeks, he then transitioned to an exercise rehabilitation programme under my supervision at the request of the surgeon. From weeks 6-12 post-operatively, the focus of the exercise rehabilitation programme was to restore pain-free shoulder passive and then active ROM and begin isometric rotator cuff activation exercises and basic Theraband exercises in preparation for moving into the strengthening phase of the programme after week 12.

On review with the treating surgeon at 12-weeks post-operatively, the surgeon was happy with progress given the complexity of the injury, and clearance was provided to commence gentle strengthening exercises. From week 12 onwards, strengthening exercises were gradually introduced whilst also keeping focused on further building and maintaining the patient’s active ROM and rotator cuff function. Overhead exercises were not introduced until 5-months post-operatively when the patient was able to demonstrate good scapulothoracic control into overhead positions. The patient made steady progress over a period of 3-months (see graph below), with weekly reviews to ensure he remained on track with his exercises and they were appropriate for his presentation and abilities.

At the 6-month post-operative review, the patient was able to demonstrate normal pain-free shoulder range of motion (symmetrical to his non-injured arm), excellent power and strength with all rotator cuff integrity testing, and had reached the appropriate milestones to facilitate a graduated return to work programme. Using the evidence from the supervised exercise programme, the surgeon was able to provide clearance for the patient to return to modified duties with a 15kg lifting restriction below shoulder height only.

The patient is due to review with the surgeon again at the 9-month post-operative mark, the goal prior to this review is to further build the patient’s strength and tolerance for work-specific physical tasks and gradually build strength and capacity for overhead movements. The exercise programme will be suitably modified to begin to replicate the critical physical demands of the job role to ensure the patient is exposed to these tasks in a controlled environment, where a focus on correct manual handling and sound technique can we implemented. The ideal scenario would be for the patient to return to his full pre-injury duties at the 9-month mark, with some possible permanent restrictions in places for overhead lifting, due to the nature of the injury and surgery completed.

Keep an eye out for further updates on the patient’s journey over the coming months!

Alixe Marion (BSc – Exercise Physiology)

Workers Compensation Specialist

Senior Accredited Exercise Physiologist

Prehabilitation in Workers Compensation: Enhancing Function, Reducing Downtime

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As the global population ages and the prevalence of musculoskeletal conditions continues to rise, the demand for orthopaedic surgeries has surged dramatically. With this increase comes a growing emphasis on not just the surgical intervention itself, but also on the preoperative phase as a critical window of opportunity to enhance patient outcomes. One of the most promising strategies emerging in this space is prehabilitation—a proactive, personalized approach to preparing patients physically and mentally for surgery. Prehabilitation can be broadly defined as a personalized exercise program designed to improve physical function and optimize recovery outcomes for any upcoming surgical intervention. In the context of workers compensation, prehabilitation offers additional value. By maintaining or even improving a patient’s physical function prior to surgery, individuals are often able to remain engaged in modified or light-duty work roles. This not only supports their psychological well-being and financial stability but also contributes to faster and more sustainable return-to-work outcomes post-surgery. A recent meta-analysis by Punnoose et al. 2023, found that a targeted prehabilitation program increased muscle strength, improved joint function and led to a higher health-related quality of life (HRQOL) scores. These findings were consistent with patients undergoing Total Knee Replacements (TKR), Total Hip Replacements (THR) and lumbar spine surgery. Some clinical applications are listed below: Targeted approach of 4-6 weeks, with 2 sessions per week. This aligns with physiological evidence suggesting that a minimum of 4–6 weeks of strength training is needed for neuromuscular adaptations. Mixture of supervised and unsupervised intervention Multimodal programs (e.g. combining exercise with education or psychological support) may enhance outcomes By improving outcomes and reducing recovery timeframes, prehabilitation stands out as a cost-effective, proactive approach to treatment.  James Chandler Workers Compensation Specialist ‑ Team Leader South (AEP, ESSAM) Exercise Rehabilitation Services – WA

How to Fit Exercise into Your Lifestyle

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As Exercise Physiologists, a large part of our role is to empower an injured worker to integrate exercise into their lifestyle – something that is easier said than done for everyone! A common misconception about exercise, is that, for an effective workout, it must be a gruelling 1-hour session in a gym or a 10km stomach churning run, however this is not the case! Here are some alternatives and strategies to gradually make positive changes to your life: One easy way is to add movement to tasks you already do. Walking or biking instead of driving short distances, taking the stairs instead of the elevator, holding your newborn as you perform a few quick (and safe!) squats or completing short exercises during TV commercials are simple ways to stay active without setting aside extra time. Another is to schedule ‘mini’ workouts like any other appointment. Set aside just 20 to 30 minutes a few times a week—whether in the morning, during lunch, or in the evening. Utilising exercise equipment that we give you during our initial assessment and picking a handful of exercises that you may particularly enjoy, is a great shorter alternative. Treating these moments as important and ‘you’ time can help build a consistent habit. Exercising with others can make it more fun. Invite a friend for a walk, join a fitness class, or play a sport with family. When you combine social time with physical activity, it feels less like a task and more like enjoyment. The same goes for a sport or hobby that you may like, whether it’s swimming, yoga, hiking or dancing! Experimenting with the introduction of one of these strategies can be an easier first step to making a positive lifestyle change. With a little planning and creativity, exercise can become a natural part of your lifestyle, helping you stay healthy and energized without adding stress to your day. Alexander Gerry Workers Compensation Specialist (AEP, ESSAM) Exercise Rehabilitation Services – WA

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