Oct 1, 2018Work in Progress: Addressing physical and mental rehab
When an athlete faces one injury after another, recovery is an ongoing process. Open communication and consistent check-ins can make the journey smoother.
Some athletes are fortunate to go their entire careers without so much as a muscle strain, while others seem constantly bitten by the injury bug. When working with the latter group, a deft approach is required to help them navigate setback after setback.
The biggest challenge with these cases is the physical and mental toll they take on athletes, which requires athletic trainers to address both physical and mental health during rehab. Sometimes, this means having difficult conversations or even asking the toughest question of all: Should the athlete continue in their sport?
With “Brittany,” a recently graduated gymnast at the University of Utah, we went through just about every emotion and scenario you can think of in her various rehabs. She had absolutely rotten injury luck with her left shoulder. Coupled with a chronic condition that severely limited her at times, she underwent a tremendous amount of stress during her collegiate career.
But in the end, Brittany got through it all with dedication, perseverance, and being honest about her abilities. She completed four years of NCAA Division I athletics, and, more importantly, left the sport on her own terms.
Unexpected diagnosis
In late summer 2014, Brittany entered her freshman year at Utah with a history of a labral tear and multidirectional instability (MDI) in her left shoulder. Our team physician assessed her and prescribed a rehab protocol that she continued into the fall.
Around this time, Brittany started experiencing numbness and tingling in her left hand and forearm, which was later revealed to be exertional compartment syndrome separate from the MDI. She was removed from the uneven bars but continued to perform on the balance beam and floor. At the end of the season, she underwent surgery to address the exertional compartment syndrome.
Four weeks post-op, Brittany complained of fatigue and deep aching in her feet, knees, and wrists. We performed blood work to assess for a multitude of inflammatory conditions, but everything came back negative.
In the meantime, Brittany’s symptoms worsened. She said it felt like her feet were breaking when she got out of bed in the morning, and she had to soak in a hot bath before starting her day.
More blood work led us to suspect rheumatoid arthritis (RA), which was confirmed by a rheumatologist via ultrasound. RA is usually diagnosed in women between the ages of 30 and 60, so it is rare to see it in someone Brittany’s age.
While Brittany was upset about the diagnosis, she was relieved to have some answers. She had tons of questions about how to move forward, so I did a lot of research about the disease and uncovered as many tips as possible to help her.
Given that gymnastics places extreme stress on the joints-the main areas affected by RA-we weren’t sure whether Brittany would be able to continue with the sport. But she was determined to keep competing, so we started her on prednisone, meloxicam, and methotrexate. This combination worked well and kept her symptoms mostly under control. Any flare-ups in her wrists were managed with cortisone injections.
Shoulder setback
I was proud to see Brittany battle back from her RA diagnosis, and she was cleared to fully return to gymnastics for her sophomore season. Only, her success was short-lived.
During a March meet, Brittany told me it felt like her shoulder had “come out” during her beam routine. My initial exam showed full, pain-free range of motion (ROM); 5/5 manual muscle tests (MMT) for elbow flexion, shoulder abduction, adduction, flexion, and internal and external rotation; and negative shoulder relocation test. She had no issues or pain during her floor warm-up, so she proceeded with the event. However, she visibly struggled through the routine following her first pass and was immediately assessed by the team physician.
An MRI the next day revealed a superior labrum anterior and posterior (SLAP) tear with bicep tendon involvement. Surgery would be needed, but we determined it could wait until after the season. The postseason was coming up, and Brittany wanted to participate as much as possible.
From March 14 to March 21, no gymnastics was allowed. Brittany did passive ROM work, ultrasound, and Game Ready. As she improved, active ROM was incorporated, along with rotator cuff strengthening and scapular stabilization exercises. More functional exercises were added into the rehab program on March 25, including arm circles, handstands against the wall, backward jumping with arm throws, and forward jumping with arm throws.
Balance beam doesn’t require as much explosive energy from the shoulder as the other gymnastics events, so we focused on that in the postseason and pulled Brittany from the floor lineup. Progression onto the balance beam began on March 28. She was given the green light to compete in the regional meet on April 1, which she did with no issues.
Brittany went on to earn second-team All-American honors on the balance beam that season. After nationals, we scheduled shoulder surgery for the end of April.
New complications
The surgery was successful but not without problems. The surgeon discovered that besides the SLAP tear with bicep tendon involvement, there was also a Bankart lesion, capsular damage, and tearing of the rotator cuff tendon. Fixing everything required almost an entire shoulder reconstruction. However, the capsule was left alone to preserve Brittany’s ability to do gymnastics. After the procedure, she was placed in a sling for six weeks.
At around this time, she had a major complication with her RA. Per the orthopedic surgeon’s orders, she stopped taking her RA medication for two weeks before and after surgery, causing a major flare-up in her symptoms.
Once back on her medication, Brittany started having side effects, one of which was significant hair loss. We lowered the methotrexate dosage to combat these issues, which lessened the hair loss. But this caused her wrist flare-ups to become more frequent and severe, so we had to rely on the cortisone injections more often. Brittany’s rheumatologist monitored the situation as we went along so that no permanent damage would be caused.
We began rehab six weeks post-op. Things went smoothly, with ROM returning rapidly. We started strengthening exercises with scapular stabilization and grip strength and slowly moved into working on rotator cuff and bicep strength. If Brittany had a wrist flare-up, we changed the exercises or got creative by strengthening without flexion of the wrists. This involved using cuff weights or tying a Theraband around Brittany’s forearm so she didn’t have to grip a weight or hold the band.
Four months post-op, the orthopedic surgeon cleared Brittany to start progressing back into gymnastics activities. We began with weight bearing, hanging, and arm swings.
At this point, Brittany and I had many conversations about the reality of her injury. She had already been through a lot, but she was tenacious-I mentioned retiring from her sport twice, and she wouldn’t hear anything of it. She was determined to help her team in any way she could.
That meant switching up her events based on what her shoulder would allow her to do. Brittany was a natural on beam, and I knew we could get her back on that event. I told her that we would try for floor, as well, but there weren’t any guarantees.
Of course, this was a tough adjustment for Brittany-no gymnast wants to be told they can’t do something! I tried to be a positive influence during this time by focusing on what she could do instead of what she could not do. Being open and listening to what she was struggling with day-to-day helped a lot, too.
While Brittany was a particularly strong athlete mentally and physically, she experienced breakdowns and days when we couldn’t accomplish much in rehab because the focus had to be on her mental health. So, we would incorporate games into her exercises to lighten the mood, sit and discuss her current pains and frustrations, or have long talks about fashion and current events to provide a distraction. We spent many hours together every day, so I was able to check in with her, assess her mood, and talk with her if she ever got down on herself.
Dislocation dance
Brittany was finally cleared by the doctor in early September of her junior year but soon hit another obstacle. While practicing for her beam dismount, she felt her shoulder slide out of place.
When she got to the athletic training room, I relocated the shoulder and applied ice, but Brittany was clearly worried and in pain. Upon examination, ROM was limited, Speeds test was positive, internal rotation with flexion was bothersome, significant scapular dyskinesis was discovered, and MMT showed decreased strength with flexion, abduction, and empty can. After a call to the orthopedic surgeon, we decided to see how she did over the upcoming weekend.
By Monday, Brittany’s ROM had significantly improved, and while she reported stiffness, there was no pain with motion. We set to work doing joint mobilizations in conjunction with strengthening and ROM exercises to correct the scapular motion in her shoulder.
Within a month, Brittany was back on track with balance beam, and we shifted our focus to creating a routine that had minimal weight-bearing positions. We honed in on end-range strengthening, speed of arm swings, and explosiveness to reach this goal.
Ultimately, Brittany was able to compete on the beam in every meet of her junior season-a huge success in my book. However, her shoulder subluxation events became more frequent as the year went on. After consulting with the orthopedic surgeon, we determined that because of the laxity in her shoulder ligaments and capsule, these episodes were most likely going to continue. The surgeon was not concerned with any long-term effects, as long as pain subsided quickly and ROM and strength returned before she resumed sport activities.
Long-term plan
During the summer before Brittany’s senior year, we began to think long-term about managing her RA after she graduated. Up until this point, Enbrel-a very intense, costly RA drug-had been avoided in hopes we could manage her symptoms without it.
However, the corticosteroids were becoming less and less effective on her wrist flare-ups, and we didn’t think we could increase the methotrexate dosage without Brittany experiencing major hair loss again. To ensure her basic quality of life going forward, we decided Enbrel would be the best option.
The process of getting the drug pushed through insurance and covered by the athletics department proved to be tedious and time consuming. Insurance needed specific documentation from the doctor’s office, which then got forwarded on to a specialty pharmacy. The pharmacy then worked with Enbrel and another company to cut the cost.
After about two-and-a-half weeks, the first shipment of drugs arrived. Enbrel must be refrigerated at all times, can’t be shaken, and is delivered via weekly injections. While the injections are painful, the relief in Brittany’s RA symptoms came within the first two treatments, with full relief happening after about six.
Brittany was definitely freaked out by the intensity of having to get weekly shots. What ultimately helped her get past this was how well the drug worked. At that point, we were able to discontinue prednisone and all wrist injections, and Brittany had only minimal RA flare-ups going forward.
Final push
The only event Brittany could compete in her senior season was balance beam, but she didn’t let this bring her down. Instead, she threw herself into being an asset to her teammates in other areas. For instance, she was team captain for the second year in a row and served on the Student-Athlete Advisory Committee. We continued rehab through the season to maintain her scapular stability and motion.
Everything was going smoothly until late February. Brittany came into the athletic training room with shoulder pain and bruising down the length of her bicep. With the worry of a rupture, she was immediately pulled from practice.
An MRI showed that she had torn off one of the anchors from her previous rotator cuff repair without damaging the bicep tendon itself. By this point, Brittany was so numb to the idea of another roadblock that we just had to laugh at how ridiculous the whole situation was. She was allowed to return to activity, and our focus was managing her pain and strength. We used Game Ready, massage, and scapular mobilization to do this.
As a result of our efforts, Brittany was able to finish out the season. Although it was an up-and-down year performance-wise, she competed at the national championships, where the team finished fifth. After the season, she won the 2017-18 Pac-12 Conference Tom Hansen Medal, which commemorates outstanding academics, athletics, and leadership.
The record books, however, do not show the stress, depression, and helplessness that Brittany battled. Despite the numerous setbacks, she never gave up-she loved gymnastics and wanted to participate in any way possible. What helped get her through was utilizing her resources at Utah, including countless conversations with me and seeing a psychologist.
With her collegiate career over, Brittany must consider her long-term health. After the season, we met with the orthopedic surgeon to discuss the future for her shoulder. We agreed to wait for six months after gymnastics was done to see if the capsule would tighten up on its own. If it doesn’t, surgery will be discussed. Right now, the doctor is not concerned about any long-term shoulder issues.
For Brittany’s lifelong RA care, things are a little more up in the air. Her rheumatologist says about 50 percent of patients who develop RA at such a young age see the symptoms completely disappear in about five years, so we are all hoping Brittany falls into that category. We’re also curious how the RA will respond to her dramatic decrease in high-impact activities now that she’s done with gymnastics and if we will be able to lessen some of her medications as a result.
In the meantime, I still see Brittany once a week for her Enbrel injection. We are working out who is going to pay for the drug now that she’s graduated. Per NCAA rules, Utah covers injuries for four years after graduation. But since RA is a chronic disease, we are unsure how to proceed. There is a company that provides payment for Enbrel, which has helped a lot, but Brittany’s insurance doesn’t cover the rest. Figuring it all out is going to be a learning process for everyone.
Honestly, the past four years with Brittany have been one long learning process for me as a clinician. She tested my levels of creativity when it came to rehab, taping, and treatments. I had to come up with all kinds of different exercises to strengthen her shoulder while keeping things fun and fresh.
The biggest challenge, though, was watching Brittany be in pain every day and not being able to do anything about it. I couldn’t get rid of her RA, and I couldn’t make her shoulder stay in the socket-both of which were very frustrating for me. All I could do was listen, offer advice, and keep her as mentally and physically strong as possible.
