Post-surgical Rehabilitation Of Shoulder Triple-tendon Transfer In A Fitness Athlete

HISTORY AND CASE DESCRIPTION: A 34-year-old female fitness athlete with a medical diagnosis of left Trapezius paralysis, which caused scapular winging in protraction, secondary to peripheral nerve damage, underwent a triple-tendon transfer (T3) to correct scapular winging and restore shoulder function. The Levator Scapula transferred to the lateral aspect of the spine of the scapula, the rhomboid minor to the spine of the scapula just medial to the Levator Scapula insertion, and the rhomboid major to the medial spine of the Scapula. The patient underwent static and dynamic bracing and a modified tendon transfer protocol starting at 2 weeks and ending at 16 weeks post-surgery. TESTS AND RESULTS: (pre-op):Physical exam:Left scapula winging and protracting is observed on static posture. Limited AROM in shoulder flexion and pain on flexion and abduction on the left shoulder. EMG:Confirming a traumatic injury to the Spinal Accessory nerve. TREATMENT/OUTCOMES: (post-op): Patient-reported outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) survey to monitor the return of function of the whole upper limp and the Shoulder Pain and Disability Index (SPADI) that is shoulder specific. 1.Weeks 0 - 8: Protection phase. Full time immobilization.2.Weeks 8 - 16: Active mobilization. Avoid resistance training/stretching. Manual Therapy techniques utilized to improve the limited ROM of the Glenohumeral joint, secondary to immobilization. At the initial evaluation (8 weeks post-surgery), the patient’s DASH score was 77.5 and SPADI score was 93.8%.3.Weeks 16 - 24: Protection of repair. Decrease pain/stiffness. Biofeedback. Return to ADLs. Progressive strengthening. Avoid stretching. Introducing resistance band exercises for strengthening glenohumeral and scapulothoracic muscles, with focus on strengthening the Serratus Anterior, to make up for the inherently low capacity of the transferred muscles, especially in overhead activities. At 16 weeks post-surgery, the patient’s DASH score was 38.3 and SPADI score was 53.8%. At discharge, on week 23 post-surgery, the patient’s DASH score was 12.5 and SPADI score was 13.8%. 4.At 1 year follow-up: patient is back to exercising, including deadlifts, with minimal limitations to her left shoulder function in overhead movements.