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Shoulder rehab

April 15, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 14 — Back to Work!

Busy, busy, busy!

Yesterday was the 3 month anniversary of my shoulder dislocation caused by tripping on a sidewalk crack while jogging. The strange thing is that even after 3 months I still feel detached from this injury, like I’m watching someone else go through it and working on it as if I were my patient. When I talk about the injury and the recovery process it feels like I’m talking about someone else. I’ve read that this can happen as a result of trauma. But I think it also has to do with the fact that I am a physical therapist and therefore my natural inclination is to look at an injury objectively with an outside observer’s perspective.

I haven’t written a blog entry about my shoulder injury recovery in a while because I have been so busy with the re-opening of my office! It didn’t take long to get back up to a full schedule of patients and keeping up with that is just a little challenging with my shoulder not being 100%. It’s a common challenge that as we recover we start to add our usual activities back into our lives and the time we have to devote to rehab, rest, and recovery starts to get chipped away. So I’m working really hard to balance my time between treating myself and treating my patients. I’m so thankful to be back in the office seeing patients and clients though. This past year has taught me how much I need that for my own mental well-being!

Sleep

Right now I’m about 10.5 weeks post-surgery. A lot of things are getting much better. The biggest success I can report is that I have finally been able to sleep in my bed again for the past week or so! This is a huge deal for me and it took much longer to get to this point than I anticipated. Sleeping is one of my favorite hobbies and, not to brag, but normally I’m really good at it. While I’m thankful to have a recliner that I could sleep in, it’s just not the same as being in my own bed. I had been sleeping in the recliner since the initial injury on January 14th with the exception of a couple of failed attempts to sleep in bed. Each time I tried I would wake up after less than an hour asleep with pain in my shoulder that just wouldn’t calm down with adjusting positions. I would have to get up and get some ice on it and go sleep in the recliner. For a while it was to the point where I didn’t even want to go to sleep (even in the recliner) because I knew when I woke up I would be in intense pain. I’m still not sleeping that well — waking up with pain and needing to adjust positions frequently throughout the night and getting maybe 5-6 hrs of sleep each night — but at least now I can fall back asleep without having to get out of bed.

Strengthening

This phase of rehab is generally supposed to be a time of building strength and it’s coming along pretty well. I’ve been able to add free weights to most of my exercises and to increase the resistance level of the Theraband I’m using for others. My shoulder is tolerating working at a computer now and most of the manual therapy I normally do. I’ve had to adjust the way I do a lot of things, especially manual therapy and manual muscle testing, to use my left shoulder for any force that needs to be generated. But overall, I don’t feel terribly limited in the things I’m able to do for my patients.

Prone row with dumbbell

Prone shoulder extension with dumbbell

Standing Row using a Theraband

More on Scapulohumeral Rhythm

The biggest limitations continue to be range of motion and scapulohumeral rhythm. I had some folks send me questions about this after my last post. I wrote in that post about how the tightness of the shoulder ball-and-socket joint (aka the glenohumeral joint) is resulting in most of the motion when I raise my arm coming from the scapula moving on my back (aka the scapulothoracic joint). This must be improving on some level because the pain in my rhomboids and trapezius from being strained by the hypermobility of my scapula is starting to feel better and the relief I get after acupuncture or massage therapy is lasting longer. But some of you noticed that my injured shoulder was “shrugging” up when I tried to raise my arm. As you raise your arm the head of your humerus should glide downward to keep the ball nicely in the socket as your arm lifts. As I raise my arm no gliding is happening so my scapula has to rotate up and out to keep the ball in the socket as my arm goes up. If your humerus didn’t glide AND your scapula didn’t compensate in this way, the head of the humerus would roll right off the top edge of the glenoid. Not to worry in my case as the glenohumeral joint has been surgically stabilized and isn’t going anywhere ever again. But as you can see from the video below, that “shrug” sign is still happening. That is a sign that physical therapists look for as it tells us that either the rotator cuff is not working well to stabilize the head of the humerus (ball) in the glenoid (socket), the muscles that stabilize the scapula aren’t doing their job, or something is wrong with the joint mobility. My problem is a combination of the last two. As you can see in the video below, it’s certainly a little improved if you compare it to last month’s blog post, but still shrugging.

https://www.collegehillpilatespt.com/wp-content/uploads/2021/04/InShot_20210415_160143021.mp4

What’s to be done about this? Dave, my physical therapist, uses manual therapy to work on the joint mobility for me. But you have to be careful with hypermobile people after this kind of surgery not to push too hard to get joint mobility because we really need to avoid that glenohumeral joint becoming hypermobile again. So you can’t be too aggressive. Yesterday Dave also worked on getting some better activation from my lower trapezius muscle to help stabilize the scapula, which seemed to help quite a bit.

Shoulder internal rotation stretch while lying on the injured side to stabilize the scapula
Lying on the injured side to use my body weight to stabilize the scapula while I stretch the shoulder into internal rotation.

I’m also continuing to work on stretching that joint as much as possible on my own with the scapula stabilized by lying on it.

And of course I’m working to strengthen anything I can to stabilize the joint and the scapula including the rotator cuff muscles, which are the muscles that stabilize the head of the humerus in the glenoid socket, and the lower trapezius and serratus anterior, which work to stabilize the scapula. But I know everyone who has ever had to recover from an injury feels my pain when I say that it seems that the one thing I can’t do anything about is the truly limiting factor here — time. Some of this is just going to take time.

Filed Under: EDS, Hypermobility, Physical therapy, Range of motion, Scapulohumeral rhythm, Shoulder, Shoulder injury, Shoulder rehab, Shoulder surgery

March 15, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 13 — Sling-free and scapulohumeral rhythm

No more sling! NSAIDs are back!

I saw the orthopedic surgeon this morning for my 6-week follow-up appointment. The great news is he said I can stop wearing the sling! The other great news is now that I’m 6 weeks post-op I’m allowed to take ibuprofen again! NSAIDs can delay bone healing. Since all of the damage that was repaired in my shoulder was bone and cartilage I was not supposed to take any NSAIDs for 6 weeks. Tylenol really does not work for me at all. They prescribed Gabapentin and Flexeril (a muscle relaxer) immediately post-op, but both of those are hard for me to function on because they can make you sleepy and brain-foggy. So hooray for NSAIDs!

Opening for business!

I’m also opening my office for physical therapy patients and Pilates clients again. I’ve been seeing a few folks the past couple weeks as I tried to ease back in. Now that I don’t have to deal with the sling and have at least partial function of my right arm I’m welcoming back more of my people. I’m looking forward to seeing everyone again.

Scapulohumeral rhythm

I plan on posting again soon with my updated exercise routine. For now I wanted to write about what’s going on with my shoulder movement. When you raise your arm there is a certain amount of motion that comes from your scapula (shoulder blade) moving on your back and a certain amount that comes from your glenohumeral joint (the ball-and-socket shoulder joint). It varies somewhat between individuals, but generally the first 30 degrees of elevation is from the glenohumeral joint alone and the rest of the motion occurs in a 2:1 ratio of glenohumeral motion to scapular motion.

As you can see in this video, that is not what is happening right now for my right shoulder.

https://www.collegehillpilatespt.com/wp-content/uploads/2021/03/InShot_20210315_160607012.mp4

Due to the surgery, which among other things tightened up the joint capsule of my right glenohumeral joint, almost all of the motion is coming from my scapula rotating a whole lot on my back. Almost none of the motion is coming from my glenohumeral joint itself. My hypermobile scapulothoracic joint is more than up to the task of making up the difference for my hypomobile glenohumeral joint. But this is making my rhomboids and trapezius muscles on the right very cranky (painful) about having to do all this work to turn my scapula. So most of my pain (which at least now I can take ibuprofen for, yay!) is coming from those overworked and underpaid rhomboids. The surgeon says this is what he expects at this point, that it will get better with time and PT, and that I should stop worrying so much.

I’ll take another video when this is improved in the hopefully not-so-distant future to show you how it changes.

Shoulder external rotation range of motion

I also have very limited external rotation range of motion. This is my tightest direction. As you can see from this photo, it’s got a long way to go to be anywhere near like the other side. Ideally both hands should be able to open to the sides about equally. The surgeon says he expects it to eventually be within 10% of the motion of the other side, which would have no effect on function.Active Range of Motion Shoulder External Rotation

 

Incision scars are looking good

I’m including the following photo just because I thought you might like to see how well my incisions are healing up. There are 2 in the front of the shoulder and 2 in the back. I’ve been using Mederma on them, using my microcurrent point stimulators on them which are great for remodeling both external and internal scar tissue, and doing scar massage techniques on them daily. They are looking pretty good and will probably barely be visible in a year or so.

Back of shoulder incisions

Front of shoulder incisions

Filed Under: EDS, Hypermobility, Physical therapy, Range of motion, Scapulohumeral rhythm, Scar tissue, Shoulder, Shoulder injury, Shoulder rehab, Shoulder surgery

March 3, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 12 — The long, slow work of recovery

I haven’t updated the blog in a while for the simple reason that I just didn’t feel like I had anything very interesting to share. It’s been almost 7 weeks since I dislocated my shoulder and a little over 4 weeks since the surgery to repair my shoulder labrum and fill in the Hill-Sachs lesion (aka the dent left in my humerus from it being smashed into my scapula). I’ve been going to PT once a week and doing my PT exercises religiously (maybe manicly?) 3 times a day. The exercises are still mostly focused on restoring range of motion with a couple thrown in for preventing my shoulder muscles from completely atrophying. I’ll post my exercise program for you further down. I’ve met my range of motion goals for week 4. I have 2 more weeks until I’m free of the sling. All is on track. Nothing exciting to report.

I started back to work seeing a few patients and Pilates clients this week to try to ease back into normalcy. As I told a patient about not posting for a while because there’s nothing interesting to say he reminded me that the long, slow, unexciting pace of recovery is something that could actually be really important to post about. He was absolutely right! The chunks of time that seem to go on forever in between the big achievements and exciting realizations of recovery are where it gets hard. These lulls are where people tend to give up and stop doing their home exercises or drop out of physical therapy. But these are the times where perseverance is everything. You have to keep pushing on that long, slow uphill climb to get to the mountain tops where you can celebrate the bigger victories.

On the mental health front, unsurprisingly, I’ve also been pretty depressed the past couple weeks slogging through this process. Not being able to see patients/clients really brings me down. I’m thankful to be ramping my practice back up now. It’s not wasted on me how blessed I am that I have the type of job where I still get to see people face-to-face even in the midst of the pandemic.

On top of that I’m still not sleeping very well. I have to sleep in the sling and still can’t sleep lying in bed so I’m using a recliner.  My shoulder gets really achey and stiff and wakes me up at about 3 or 4 am. When you don’t sleep well everything seems worse. Studies show that your pain tolerance is actually lower when you aren’t getting enough sleep. What a cruel joke! You can’t sleep because you have pain, but you can’t tolerate the pain well because you can’t sleep.

Also, if we’re going to be real here, as I’ve been walking to and from my office like I usually did daily before this injury, I’ve realized that I have a fear of walking on the sidewalk. I have to keep my eyes down on it in case one of those evil sidewalk cracks tries to grab my foot again. I keep remembering the sidewalk flying up at me and the feeling of my shoulder coming out as my hand hit the ground. Sometimes I walk in the street just to avoid being on the sidewalk (only on the empty side streets of course). I’m hoping walking regularly to and from the office, just doing it anyway, will eventually help me get over that.

And now for your excited viewing pleasure I have some photos of my current home exercise program, which I do 3 times a day without fail.

Shoulder shrugs
Various versions of shoulder shrugs, shoulder rolls, and shoulder blade squeezes. The shrugs have actually been really hard for me even though they’re usually an exercise I would give someone to start on because they’re relatively easy and innocuous. To be honest, I don’t really know why they’re so hard. I’m thinking it has to do with reduced mobility at my acromioclavicular joint.

 

https://www.collegehillpilatespt.com/wp-content/uploads/2021/03/20210302_1032354721.mp4

Cervical retraction to help with alignment and to counteract the effects of wearing a sling all the time.

 

https://www.collegehillpilatespt.com/wp-content/uploads/2021/03/InShot_20210303_002024271.mp4

Wand shoulder internal and external rotation – I’m using the dowel to let my unaffected hand and arm push my surgical shoulder into internal and external rotation. The motion you see here is all I have right now, it doesn’t go any farther in or out even though I’m pushing on it. I might not ever get full range of motion back in these directions. Studies show most people in my position don’t. But that’s okay. Since I’m not trying to be a baseball pitcher or anything I will get enough motion to be functional.

 

Shoulder pulleys
Shoulder pulleys allow you to pull down with your unaffected arm to stretch the surgical arm up. I’m not really allowed to go any farther up than this at the moment. My motion has to be limited and progress slowly to preserve the stiffness of the joint that the surgeon created when he tightened up my joint capsule. That way I won’t end up back where I started with a hypermobile joint.

 

https://www.collegehillpilatespt.com/wp-content/uploads/2021/03/InShot_20210303_003343615.mp4

Bicep curls help keep my bicep from atrophying as much while I’m not using it as much as I would normally use it because my arm is in the sling. I’m using a 3 lb weight in this video. I’m thankful that there was no damage from the dislocation  to my bicep tendon as it comes up over my humerus. If there had been damage there I would have to avoid activation of my biceps so I wouldn’t be able to do this yet.

 

Rotator cuff isometrics
Rotator cuff isometrics are also to help avoid muscle atrophy. This time it’s atrophy of the rotator cuff muscles that perform shoulder external and internal rotation. My shoulder gets mad about the external rotation. I assume that’s because of the anchor through my infraspinatus muscle, which performs external rotation, into the Hill-Sachs lesion to fill it in.

In addition to all of this I’m also still using ice a few times a day and at night. I’m massaging the incisions with Mederma and using my microcurrent point stimulators, which are great at preventing and treating scar tissue, on them. I’m seeing my acupuncturist weekly, which helps a lot with pain control, anxiety, and I get my best night of sleep all week the day I see her. My rhomboids (muscles between my shoulder blade and spine) have been painful and tight so she did some cupping on them, which helped a lot. This brings me to my last point for today…

I’ve realized how lucky I am to personally know so many great health care providers. I knew a great orthopedic surgeon when I needed one, a great PT, a great acupuncturist… And I have great massage therapists and chiropractors and others that I know I can call on if (when) I’m ready and I need them. I can’t imagine going through all of this and not knowing who to see or not having that level of trust with my people. What a privilege it is for me to be the person that my patients and clients trust when they are in the midst of the long, slow climb to recovery.

 

Filed Under: Acupuncture, Hypermobility, Physical therapy, Shoulder, Shoulder injury, Shoulder rehab, Shoulder surgery

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