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SLAP II Repair in an Elite Female Rugby Union Player

Michelle Angus MCSP SRP MSc. MSOM BSc. (Hons) Physiotherapist RFUW
Dr A Ajayi MSc, MRCP, MCEM, MFSEM, Doctor RFUW
Mr L Funk BSc. MSc. FRCS(Tr&Orth). FFSEM(UK) Consultant Shoulder & Upper Limb Surgeon Honorary Professor

Abstract

Background: This case report describes how an accelerated rehabilitation program can be utilized to ensure an elite female rugby union player returns to competition in a timely manner following a Superior Labrum, Anterior, Posterior (SLAP) repair.
Study Design: Single patient case report.
Method: The study follows an elite female rugby player throughout the management of a SLAP II tear in her shoulder.  It looks at the diagnosis of SLAP lesions and both the surgical management and rehabilitation following surgery.  The incidence of such injuries and length of time out of sport are compared to previous research.
Results: The athlete in the present study was fit for selection 8 weeks post SLAP repair and played an international fixture 9 weeks post operatively.
Conclusions: Isolated SLAP lesions can undergo accelerated rehabilitation programs in elite female rugby players and return to play in a timely manner.

Key Terms: SLAP lesion, rugby union, accelerated rehabilitation, female elite athlete.


Introduction

Rugby Union is a high impact collision sport with a high incidence of injuries, previously reported as 86.4 injuries per 1000 hours played (Holtzhausen, 2001).  Despite this high injury rate little work has been done around the return to play following specific injuries in rugby union, especially of the shoulder.  Recent   evidence confirmins shoulder injuries as one of the major factors affecting time out of the game (Headey et al. 2007), and labral lesions being a common cause of pain in rugby playing shoulders (Funk and Snow, 2007).  The following case study looks at the management of an elite female rugby player who sustained a superior labrum anterior posterior lesion (SLAP lesion).  The report aims to focus on the use of an accelerated rehabilitation programme to allow the fastest possible time to safely return to play.

Method

History
The patient was an elite female rugby player, who had no history of shoulder injury and no other medical conditions.  The season was in its infancy although the intensity was relatively high; she had played 7 games including 2 England trial games in the month immediately preceding the injury as she was playing for both club and university.  Her strength and conditioning training was also of an extremely high intensity during this particular month.  She completed 25 different sessions within a 4 week period including weights, running, climbing, swimming, other team sports, hiking and rugby specific training including fitness sessions.  Only 5 complete rest days were taken during this period.  The intensity was also high prior to this; she had played a game of rugby every weekend for 10 weeks from the start of the season. 

The injury to the patients shoulder occurred during a club training session, it involved a fall onto her outstretched arm with the ball underneath the forearm and a player landing on top of her shoulder.  The shoulder in question was therefore in a position of forward flexion at 80 degrees with a slightly flexed elbow and as a result there was an axial load forcing the humeral head into the glenoid.  This mechanism was described by Snyder et al (1990) as the most common position for a SLAP lesion to occur.  She described immediate pain, and was unable to continue training.

Objective Examination
Unfortunately as is the nature of women's rugby in England there was no medical support on hand, although through telephone consultation it was established that there was a reduced range of motion due to pain inhibition.  She managed to access treatment the following day and had an ultrasound scan which showed no abnormalities.  The treating physician was happy to attempt conservative treatment in the first instance, although various studies looking at shoulder injuries in high level rugby suggest a high recurrence rate for untreated injuries of up to 62% (Headey et al. 2007; Edgar et al. 1995). 

On review the player had a positive 'SLAPrehension' or 'active compression' test (87.5% accurate in diagnosis O'Brien et al, 1998) and a positive biceps load 2 test (92.1% positive predictive value Kim et al, 2001).  She had a marked reduction in her range of movement and the muscle recruitment patterning to allow active movement had begun to alter from normal patterning.  She had increased firing of her pectoralis minor, levator scapula and serratus anterior, these muscles have previously been described as overactive muscles in shoulder injury (Comerford and Kinetic Control, 2002). 

The athlete was subsequently assessed by a consultant orthopaedic surgeon with a specialist interest in sports shoulders, who also clinically diagnosed a SLAP lesion.  She had a strongly positive O'Brien's test, with (90% sensitivity according to Pandya et al. 2008). The Constant Score was used as an outcome measure for pain, and function, she scored 31 of a possible 100 (Constant, 1987).  A magnetic resonance arthrogram with an intraarticular  injection of gadolinium confirmed a SLAP II lesion which involves a tear in the long head of biceps tendon.  An arthrogram was used as this technique improves visualisation of labral lesions (Nam and Snyder, 2003; Pandya et al., 2008).  The athlete was offered two different management options.  The first was surgery to repair the lesion as soon as able, the second was an intraarticular injection of either lignocaine and kenalog or Ostenil hyaluronan to reduce the inflammation and allow her to continue playing with the view to performing the operation at the end of the season.  The multidisciplinary team including the England head coach, physiotherapist, doctor and the player felt that the player would benefit long term by having the operation in a timely manner therefore reducing the risk of recurrent injury.

Treatment
The athlete underwent a SLAP II repair, using a standard surgical technique with a single double-loaded anchor.  Initial post operative considerations were with regard to protection of the repair and the athlete therefore remained in a master sling with a body belt for the first week as per the surgeon's protocol and was gently weaned off over a 2 week period. 

Phase 1 of rehab began 2 days after the surgery ensuring the associated joints and soft tissues did not become stiff or tight.  She was also encouraged to continue gentle lower limb work, and begin scapula control work.  Within this early stage whilst weaning off the use of the sling she began gentle range of movement and core stability exercises along with some closed kinetic chain work for the shoulder with minimal loading. 

The goal of the second phase of rehab from 2-6 weeks was to regain full, controlled, range of movement, which required some soft tissue release work on the posterior capsule.  The focus also included progressive joint loading with strengthening of the muscles that support the shoulder especially the rotator cuff.  More specific work on dynamic stability and recovery of normal proprioception was included in this phase..  Throughout this phase of rehabilitation the athlete began to build up other training, gradually returning  lower body weights to their pre injury state and a return to running.  She also began to do some gentle passing and control work with a rugby ball to attempt to restore normal movement patterns.

The final phase of rehabilitation was aimed at returning to sport specific function, and specifically a focus on the skills required by a rugby back.  Weights sessions for the upper limb were gradually increased, having been preceded by closed chain control exercises. Rugby specific work included increasing the pace and distance of passing along with preparation to begin contact training. There was good adherence to the rehabilitation programme with resultant good progress. She completed a rugby fitness test specific to the upper limb at 8 weeks post operatively, when her Constant score was 88/100 (Constant, 1987) and played an 'A' international game at 9 weeks following the operation, in which she had no problems with her shoulder. 


Discussion

Rugby union is a contact sport that has a high incidence of injuries, well documented within the medical literature to the related risk of injury (Edgar et al. 1995, Holtzhausen 2001).  Various studies have looked at the occurrence of injuries within the game.  Holtzhausen reviewed the 10 studies completed prior to 2001, finding the shoulder to range between the second and fourth most common injury site.  Yard and Comstock (2006) performed the longest running audit looking at injuries presenting to an American Emergency Department between 1978 and 2004 (a total of 4835 patients), although of these patients 87.2% were male.  Within the male group the shoulder was the second most common site of injury (14.65), although a smaller percentage (11.4) it was the most common site of injury among the female rugby players.  Bathgate et al (2002) looked at Elite Male Australian Rugby Union over one season and found that 20% of all injuries were related to the shoulder, again the second most common site of injury.  Headey et al (2007) audited the occurrence of shoulder injuries in slightly more detail, gathering data over season from all male English premiership rugby union clubs.  They found that the acromioclavicular joint was the most common site of shoulder injuries (36%) followed by instability/dislocations (15%), this study did not specify the lesions in the instability group in more detail although it can be hypothesised that SLAP lesions would fit into this group.  Malone et al described 'the collision shoulder', reporting the high incidence of labral tears in collision athletes with shoulder pain.

All studies agreed that more injuries occurred in matches than in training and that injuries were most likely to occur during contact, especially tackling.  Some studies have also looked into injury rate specific to playing position, Headey et al (2007) found that dislocations/instabilities were most likely to occur to the outside and midfield backs (62%), although they suggested that these players make fewer tackles than other positions.  Doyle and George (2004) performed the only published study to date looking specifically at women's rugby; they audited the England teams' injury occurrence over a 7 month period (35 players).  This study found that the shoulder was only the joint fourth most common site of injury and in contrast to Headey et al (2007) shoulder injuries only occurred in the forwards.  The athlete in the present study did get injured during a tackle situation as reported in all previous studies, although in agreement only with the findings of Headey el al (2007) she plays as a midfield back at outside centre.

Once the diagnosis of a SLAP II tear was made, a decision regarding timing of surgery had to be made.  Of the studies above looking at injuries both Edgar (1995) and Headey (2007) found that the shoulder was the most common site to have recurrent injuries, these recurrences accounted for more time out of the game than any other injury.  A study into the management of SLAP lesions (Nam and Snyder, 2003) found that 'in general, non-operative management has proven unsuccessful'.  This information along with the risk to the player of further more severe injury helped make the decision to have the operation at the earliest possible opportunity.  It is vital that this decision making involves all the multi-disciplinary team including the athlete and coach (Van Mechelen, 1992), to ensure trust and clarity between all members of the team.

There has been little published work specific to rehabilitation following a labral repair, although the surgeons post operative protocol is based on strong anecdotal evidence and knowledge of tissue healing.  The initial inflammatory phase of healing generally lasts 1 to 3 days, which is why the sling was worn continually throughout this phase.  Following this is the tissue repair or proliferative phase where fibroblasts begin synthesizing collagenous scar tissue, bonds that develop between the new strands of collagen can be damaged by aggressive tension, therefore during the early part of the second phase of the rehab only gentle and low load exercises were performed, although due to the collagen forming cross fibres it was important to begin to regain full range of motion during this phase of healing.  Knowledge of the surgery and involvement of the long head of biceps tendon also ensured this structure was protected throughout these early phases.  This knowledge was used and the surgeons' protocol followed as a guide splitting the rehab into 3 phases with differing aims, although the surgeon was happy to allow the rehab to accelerate according to the progression of the patient.  The only published work looking specifically at rehabilitation following a labral repair (Blackburn and Guido, 2000) describes various aspects of rehab that were followed in the present case study.

There are two slightly different uses for the kinetic chain in shoulder rehabilitation.  The first can be incorporated from early in the rehabilitation process, as the shoulder rarely functions as an entity of its own it is often accompanied by movement elsewhere in the chain.   Phase 1 of the rehabilitation in the present case study included low level lower limb and scapulothoracic work with the sling in situ in order to facilitate normal movement patterns.  This can then be developed throughout the rehabilitation process using normal muscle patterning as suggested by McMullen and Uhl (2000), who looked at muscular co-contraction prior to shoulder flexion and suggested the use of exaggerating these patterns by facilitating the work of the hip flexors using a step.  The second use of the kinetic chain involves closed kinetic chain exercises, which have been shown to facilitate recruitment of the rotator cuff (Dillman et al. 1994).  Again these exercises at a low intensity were started early in the rehabilitation process, during phase 2 when the sling could be removed for exercise weight bearing exercises were included in the rehabilitation programme.  Throughout the rehab closed kinetic chain exercises could be progressed to challenge the body in different ways including strength and Proprioception.

The use of plyometric training in the rehabilitation of the lower limb to promote proprioceptive control and joint stability has been widely documented; its importance in the rehabilitation of shoulder injuries is becoming more understood.  Swanik et al (2002) looked at the effects of a six week shoulder plyometric programme on female swimmers and found significant improvement in their proprioception, kinaesthesia and muscle torque in the internal and external rotators.  Although these athletes were not injured the results may suggest that plyometric training be incorporated and shoulder rehab programme and was included in phase 3 of the present case study.

The rehabilitation following any injury must also contain sport specific work, due to the very different demands required in rugby union it also important to make this position specific (Eaton and George, 2006).  Theirs' is the only work done on the specific rehabilitation demands on the body in the northern hemisphere, it suggested that inside backs must work on high intensity running and tackling/being tackled. Although this data did not include changing direction which the authors acknowledged to be important for this position.  The other important aspect of play for the athlete's position is her ball handling which again was not included in the report.  Running was included in the rehabilitation of the athlete in this case study as soon as she could tolerate the movement with no shoulder pain.  She was encouraged to do this with a rugby ball in her hands in order to facilitate normal function for her, and to attempt to provide some increase in muscle tone of the rotator cuff through neuromuscular stimulation from her hands.  This was progressed to sprinting as tolerated, along with work without the ball.  The other important aspect of the game for this player was ball handling; this requires different biomechanical demands depending on the direction, speed and length of the pass.  Again to use normal muscle patterning and recruitment for this player passing was included in phase 2 of her rehabilitation as soon as she had the range of motion to perform this skill.  Other development of this skill included the use of floatation devices in water and theraband to offer resistance.  As the player improved with the ability to perform this skill the rugby coaches became involved in assessing and improving her control.

The build up to contact did not begin until she had returned to all her other training, although on reflection light contact through the shoulder would have begun to restore normal muscle patterning at an earlier stage.  This aspect of her training was done with the support of both the physiotherapist looking at her movement patterning and muscular recruitment and rugby coach who gave her feedback on her technique.  Again, highlighting the need for a team approach to rehabilitation.

The whole rehabilitation process took 8 weeks until she was fit for selection, and she played an England 'A' international game at 9 weeks post operatively with no adverse effects.  Funk and Snow (2007) performed a retrospective study looking at SLAP tears in professional rugby players and found the average time for returning to play was 2.6 months for isolated SLAP lesions.  With the only previous literature looking at rehabilitation regimes ranged from 4 to 12 months of rehabilitation.

Conclusions

The present case study supports the suggestion by Funk and Snow (2007) that isolated SLAP lesions can undergo an accelerated rehabilitation programme.  The rehabilitation can be split into 3 phases governed by the healing process, although some concepts of rehabilitation span across all 3 phases.  It also highlights the importance of a team approach to the rehabilitation of injured athletes, with patient orientated goals throughout the process.  Little work has been published looking at injuries in women's rugby, although the present study suggests that the rehabilitation is of a similar approach to that in the men's game despite the amateur status of the women's game.


References

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