Hypermobility

January 25, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 4 — Surgery Scheduled

I saw the orthopedic today and based on the MRI he and I agreed that without surgery this shoulder is all but guaranteed to dislocate again so we are going ahead with surgery. He said the joint capsule (the usually dense, fibrous connective tissue that forms a sleeve around the joint and encloses the joint space) is so stretched out “it looks like you could drive a truck through it.” He said he would normally schedule it for this Wednesday but due to the pandemic I have to have a negative COVID test five days prior to surgery. So I’ll have a COVID test tomorrow and surgery on Monday, Feb 1. I also have to have a history and physical from my primary care physician.

The surgery entails a Bankart repair – suturing or anchoring the labrum back to the glenoid (socket) where it belongs, capsulorrhaphy – tightening the joint capsule with sutures, and remplissage – anchoring the infraspinatus muscle and posterior joint capsule into the Hill-Sachs lesion (compression fracture dent in the head of my humerus) to fill it in. It’s a lot of work to do but it will all be done via arthroscopy or “scope.” He actually said he can see the joint better from all sides using this way than he could with an open procedure. I’m relieved by this because it means less muscle damage and less scarring.

Remplissage- anchoring the infraspinatus and posterior capsule to fill in the Hill-Sachs lesion.

After surgery I expect to be in quite a bit of pain for the first week or so. I will have to be in a sling for 4-6 weeks to protect all of these repairs and plan to take at least 2 weeks off seeing patients at all and then limit my schedule to those needing minimal or no manual therapy for at least 4 more weeks after that. It will be 3 months to get back to somewhat normal day-to-day function and then up to a year for full recovery. But my shoulder will be much more stable forever and very unlikely to ever dislocate again. So it will all be worth it.

Since the blog has mostly been academic so far with descriptions of the injury and anatomy, some folks have been asking how I’m feeling about all this. I’m mostly very sad about it. Sad about the damage and about being sidelined from seeing patients and all of the other things I love to do. And I’m anxious about the surgery because, while I’ve never had shoulder surgery before, I’ve treated many patients after shoulder surgery and I know how painful it is. But I’m also looking forward to having a much better shoulder that doesn’t feel unstable anymore. It’s just going to be a long road to get there.

I’m also having flashbacks about the actual incident–the trip, fall, and feeling of it dislocating. I can barely stand even to see other people running. And I’m never planning on running outside again! I didn’t like running to begin with!

And finally, I’m feeling frustrated and annoyed that this is all happening during the pandemic and the ways that complicates matters. It’s difficult to figure out how to accept badly needed help because we aren’t having anyone in our house outside of our little nuclear family. I should be getting my second dose of the Moderna vaccine on Feb 6, which will not be fun if I’m dealing with post-op pain AND get the side effects of muscle pain, fatigue, fever and chills that some people seem to have with their second dose. And I’m trying to figure out who I will see for PT after surgery. I want to find someone who is being as cautious about COVID as I am, which is a tall order.

Stay tuned for more!

January 23, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 2 –The First Orthopedic Visit

One of the great benefits of being a physical therapist is knowing who the best doctors are for any musculoskeletal issue you may encounter. The orthopedic surgeon that I’m seeing is someone who I refer patients to when I feel they need a consultation. Although I have never met him in-person I feel like I have because I’ve seen so many patients from him and sent so many to him over the years. I always say, “If it was my shoulder I would see Dr Favorito.” So now it’s time to put my money where my mouth is! I got an appointment for Tuesday, January 19.

At the orthopedic office, I started by getting several more X-rays–different views than the hospital took. Dr. Favorito is very thorough and is sure to view the joint from every possible angle. When he entered the exam room he said, “Well, I didn’t think THIS is how we’d be meeting!” And of course I agree! He took a thorough history and did an exam, gently checking sensation, muscle strength, and function in the injured shoulder.Axi

The sensation to light touch on my shoulder is very diminished and my deltoid muscle is very weak. This indicates damage to the axillary nerve, which wraps around the humerus and would have been overstretched with the dislocation. This should improve over time but it will be a very slow process as nerves are the slowest healing tissue in the body. On average, peripheral nerves like this one regenerate at a rate of one inch per month.Hill

The X-rays showed a Hill-Sachs lesion on the head of the humerus. This is a compression fracture on the back side of the humeral head (the “ball” part of this “ball and socket” joint) from where it impacted into the front of the glenoid (the “socket”) when it dislocated. Basically, it’s a dent in the humerus. This is a problem not just for the obvious reasons but also because it is more common to have a Bankart lesion when a Hill-Sachs lesion is present.

A Bankart lesion is the name for a tear that happens in the lower rim of the labrum, which is the ring of cartilage around the glenoid. It is 11 times more common in patients with a Hill-Sachs lesion. Once the labrum is torn, it’s much easier for the humerus to slip out of its socket. And that is something I NEVER want to experience again!

Dr Favorito sent me out with a much better sling and an order for an MRI, which is what we need to be able to see the labrum.

Read part 3 to see how the MRI turned out!

January 23, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 1 — The Injury and ER

Early in the morning on Thursday, January 14 I headed out for a run with plans to do intervals to try to get my steps in before work. I was coming around a bend about a quarter mile out when I caught my toe on a crack in the sidewalk and fell forward. I put my hands out to catch myself and fell mostly to the right. My hand stayed on the ground out in front of me as my body rolled to the right and I felt my right shoulder dislocate. Since I am hypermobile and my shoulders have never been very stable, I initially thought maybe it was just subluxated and maybe it would reduce by itself but as soon as I tried to move to stand up it was searing excruciating pain like I have never felt before.

My dislocated shoulder — The X-ray from the hospital showing my shoulder dislocated anteroinferiorly.

After walking the quarter mile home in agony my husband drove me to the closest hospital Emergency Room. I was given an intramuscular injection of morphine in a (failing) effort to make getting X-rays tolerable. The X-rays showed, to no one’s great surprise, that the shoulder was dislocated anteroinferiorly and pretty spectacularly far from where it is supposed to be. They also showed that there were no fractures so it would be safe to reduce it without surgery. It was decided they would reduce it under conscious sedation and I was given Ketamine. That was I think the strangest experience of my life–a bit of an out-of-body experience and so, so trippy. They were able to reduce it without difficulty, gave me possibly the world’s worst shoulder sling and sent me on my way with instructions to follow up with an orthopedic.

Pain is tolerable as long as my shoulder is in the sling. It feels extremely fragile when it’s not in the sling and there’s searing pain through it if I move it outside the sling in a bad direction. I’m using cold packs and electrical stimulation, which of course I am lucky to have easy access to as a PT, on it for pain control and to reduce inflammation

Unfortunately, being a physical therapist, I know all of the potential damage that could have occurred. I’m thankful that there were no fractures, but beyond that there can be rotator cuff tears, labral tears, compression fractures to the head of the humerus, problems with the biceps tendon, overstretching of the joint capsule and nerve damage.

Read Part 2 to learn about how the orthopedic visit went as I start to figure out exactly how much damage I’ve done!

May 21, 2020 By Mindy Nagel, PT, DPT, OCS

EDS and Tight Muscles: If My Joints Are So Loose, Why Do I Feel So Tight?

A common question I hear from my patients and clients who have been diagnosed with Ehlers Danlos Syndrome (EDS) or Hypermobility Spectrum Disorder (HSD) is, “If my joints are so loose, why do I feel so tight?” A feeling of tightness of the muscles, often resulting in pain and discomfort is very common among those with these diagnoses. EDS and HSD cause increased laxity of the ligaments, which causes “looseness” of the joints. The brain will do whatever it can to attempt to stabilize the joints. One of the things the brain can do is instruct the muscles surrounding the loose joints to increase their tone. This increased muscle tone can help improve joint stability. However, this can also result in the muscles staying in a hypertonic state. Hypertonic muscles do not fully relax but instead stay “on” all the time.

This hypertonicity can become a problem first because muscles that never relax are not able to use the muscle pumping mechanism to move waste products out of and nutrition into the muscle cells resulting in muscle pain, aching and soreness from accumulation of waste products or this lack of nutrition to the muscle cells. Additionally, this can result in relative weakness in that once a muscle is fully contracted, it cannot contract more. So a muscle that is already being held in a constant contraction just to stabilize a joint will not be available to contract much further to generate strength when it is called upon to do so. Third, this increased muscle tone is often not balanced around the joint. Ideally the muscle forces around the joint would be balanced so that they would result in what is known in Dynamic Neuromuscular Stabilization (DNS) as functional joint centration. Functional joint centration allows for utilization of maximum surface area contact within the joint with balanced co-activation of all the muscles around the joint.¹ When muscle tone around the joint is not balanced it can result in increased risk of subluxation or in injury as a result of focused compression and poor joint loading. And finally, the constant work being done by the muscles to maintain this hypertonicity results in fatigue, which can explain why many patients with EDS and HSD report physical exhaustion with typical daily tasks.

437.1 - shoulder NorMal1 “437.1 – shoulder NorMal1” by iem-student.org is licensed under CC BY-NC-SA 2.0

Often when people suffer from pain and fatigue resulting from a feeling of tightness in their muscles they seek out release techniques such as massage and myofascial release work either from a practitioner or through self-massage practices using balls, rollers, sticks, etc. This can be problematic when this hypertonicity is a functional adaptation of the body to deal with the laxity of the ligaments. If the release work is successful then the joints will no longer have whatever stability was being provided by the hypertonicity. Release work without retraining the correct muscle activation for functional joint centration can be disastrous for those with hypermobility. In most cases the brain will re-engage the hypertonicity as soon as possible to stabilize the joints. So at best the release work will be almost immediately undone. At worst the release work will result in instability and risk of subluxation of the joints. In my physical therapy treatment I use rehabilitation techniques from DNS to help my patients attain functional joint centration. This enables them to use their muscles to stabilize their joints in the most efficient way possible while still allowing for full freedom of movement of the joints and without resulting in fatigue, tightness and pain.

For more information on EDS-HT, HSD, as well as other EDS subtypes I highly recommend checking out The Ehlers-Danlos Society.²

May 7, 2020 By Mindy Nagel, PT, DPT, OCS

Effects of EDS on Vision

Ehlers Danlos Syndrome (EDS) is what is known as a connective tissue disorder. Connective tissue provides support and holds the body’s tissues together. It is made up of a small fraction of cells in a larger extracellular matrix. The extracellular matrix is composed of collagen, elastin and reticular fibers.¹ One of the fundamental mechanisms known to produce EDS is deficiency of collagen-processing enzymes. This results in the structure and strength of the collagen fibrils being compromised.² Collagen makes up 80% of structures in the eye. At least six types of EDS have been identified and genetic testing has been developed for all but hypermobility-type EDS. The type that most severely affects the collagen of the eye is the very rare Kyphoscoliosis Type (formerly type VI).³ Due to the specific enzyme affected by this type of EDS causing weakness in the formation of collagen of the eye, the eye can be perforated with very little trauma.⁴ This type of EDS is very rare, with fewer than 60 known cases worldwide.⁵ However, other types of EDS can also affect the eye and vision due to the similar types of collagen-weakening mechanisms.

“File:Keratoconus21.jpg” by William Charles Caccamise, Sr, MD is licensed under CC BY-SA 4.0

Common ophthalmologic considerations for EDS include myopia (near-sightedness), glaucoma and retinal detachment. Another common ocular complication of EDS is keratoconus-a condition in which the cornea bulges outward and then gravity pulls it downward causing blurred vision that isn’t fully corrected even with glasses or contact lenses. This can be treated with rigid contact lenses and various surgical options. Blue sclera may occur in patients with EDS, this is a blue appearance of the whites of the eyes caused by thinness of the sclera. Angioid streaks, generally harmless in themselves, indicate connective tissue disorder as they are breaks in one of the connective tissue layers of the eye and should be monitored for abnormal growth of blood vessels in these cracks. Redundant or drooping skin of the eyelid may be present due to eyelid laxity.⁴ Dry eyes are also very common in patients with EDS affecting 63% of patients. This may be due to impaired closure of the eyelids resulting in overexposure of the eyes to the environment.⁶This dryness can then contribute to another common EDS-related ocular issue- light sensitivity, known as photophobia. Strabismus or abnormal alignment of the eyes either toward a cross-eyed alignment or to the opposite away from midline alignment is another common and not well understood EDS-related issue. This too can be surgically corrected, but surgery is not a good choice for first-line treatment for patients with EDS due to the complications it causes with healing.⁷

People with EDS should see an optometrist or ophthalmologist for a comprehensive baseline and exam and then annually for follow-up. It is important to have a relationship with a professional who can determine if any issues that come up are EDS-related and treat them accordingly. Problems that would require intensive evaluation in a patient with EDS include blurred vision or double vision that comes and goes, complete/almost complete vision loss in one eye, migraine auras, dry eyes, light sensitivity, tunnel vision, and floaters. Emergency assistance should be sought if a person with EDS experiences double vision that starts suddenly, flashes of light, pain, redness or discharge, curtain coming up over vision, frontal headache in which patient “hears pulse in the temple,” or sudden change in vision.³ These issues can indicate vascular damage and increased risk of life-threatening arterial rupture in patients with vascular types of EDS.

I help many patients with EDS by giving them tools to manage and treat their musculoskeletal complaints. I am not an expert in vision therapy or eye care. This blog article is meant to be purely informational. If this subject interests you I recommend you check out the references below. As stated above, please consult with an eye care professional for more information about how these issues may affect you.