Shoulder

February 1, 2022 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, One Year Later

I haven’t posted an update about my shoulder rehab process since last April, which is when I returned fully back to work. Not really a coincidence!

As of today it has been one year since my surgery to repair my torn labrum and Hill-Sachs lesion. For anyone just now catching this blog, I dislocated my shoulder when I tripped on a sidewalk crack and fell while jogging early in the morning January 14, 2021. I have been working very hard all year to rehab my shoulder. I would say it’s about 95% recovered at this point. I’m hopeful that there is still some improvement to be seen.

It has been a challenge to regain the mobility and rebuild the strength at the same time. I’m happy to report that my range of motion is nearly 100%. Functional reach behind my back is still a little limited but good enough to fasten a bra behind my back or loop my belt around the back of my waist. My strength is also mostly back to normal. I am able to do all of my work activities, including manual therapy, that I would normally do. I don’t notice many functional limitations at home either and was even able to return to playing tennis with my family this summer.

The big issue is still that pesky scapulohumeral rhythm, especially when I reach forward and up overhead.

You can see that my scapula still wings a little bit as I raise my arms up and down. This is caused by the continued limited range of motion of the actual ball-and-socket joint of my shoulder. So more of the motion has to come from the shoulder blade moving excessively. This causes pinching of the soft tissue structures in the subacromial space because the humeral head does not glide downward as it rolls upward. As a result, these impinged structures cause pain. This pain is the biggest problem that is yet to resolve. I notice it the most at night because I still wake up several times a night in pain. If I spend too long in any sleeping position, it becomes painful and wakes me up. Happily, I am able to fall back asleep once I shift positions are rearrange myself. But my ultimate goal is to not wake up at night due to pain.

Glenohumeral joint arthrokinematics — On the left we have normal joint arthrokinematics. On the right you can see the pinching above the humeral head (the “ball” part of the joint) that results from altered joint mechanics.

Even though it has been a full year since surgery, I feel like this is still slowly getting better. So there is still more room for improvement. I plan to continue working on loosening up the part of the joint capsule that is still restricting this movement, strengthening the scapular stabilizers, and working on neuromuscular control of the entire pattern. So I’m still hopeful it will get even closer to 100%.

I can’t round out this year of shoulder rehab without mentioning a little bit about my continuing work to recover mentally and emotionally from this injury as well. While tripping on a sidewalk crack might not seem all that traumatic or frightening, it really affected me. I still have anxiety about walking on the sidewalk, especially if it’s dark outside. I haven’t been able to run since this injury, and even watching other people run on the sidewalk gives me a lot of anxiety. (Run on the street, my friends!) I see this a lot with my patients. We develop avoidance behaviors, consciously or subconsciously, because something we did caused us pain. Sometimes it’s something big and traumatic, but sometimes it’s something little like hurting your back when you bent down to pick up a sock. So ever after you have fear that you’ll relive that pain whenever you pick up a sock. Or maybe you felt a tweak in your back and ignored it and a few days later that tweak turned into intense pain down your leg. So now every little tweak you feel sets off alarm bells. I began seeing a mental health counselor a couple of months ago to try to work through some of this because, while running is not my favorite thing to do, I would like to be able to do it if I feel like it without fear or dread. And as a PT I do need to be able to watch my patients run now and then to analyze a faulty gait pattern. I’m hopeful that working through some of these issues on the mental health side of the equation will also help me get to full recovery and prevent this incident from affecting what I can do for any reason, physical or mental.

Nothing is lost of course. This experience has given me more empathy for my patients, though that empathy has probably actually made me a tougher rather than an easier PT! (I’ve been through it, you can do it too!) Feeling the tightness and tension in my own shoulder has helped me understand the way some of the treatments I perform and prescribe for my patients feel, and how they can help. Prior to this injury all of my joints were so loose and hypermobile that I had a hard time understanding what restricted joint mobility feels like. Now I know!

I hope that in writing about my experience with this challenge I’ve helped people have a better understanding of injury, whether their own or someone else’s. I hope that reading this reminds you of the awesome resilience and general coolness of the human body and, of course, of the power of physical therapy!

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.

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.

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.

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.

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.

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.

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.

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

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** 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.

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** 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.

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

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 11 — Proprioception and Joint Position Sense

It’s been a week since my first physical therapy appointment, two weeks since surgery, and I’ve been working hard on my home exercises. My hardest exercises are the ones geared towards increasing my range of motion to achieve my first goal — 120 degrees of forward flexion and 20 degrees of external rotation at 4 weeks after surgery. As I’ve mentioned before, my shoulder is VERY tight. This is by design. After the dislocation my shoulder was much, much too loose. Along with the repair work he did, the surgeon tightened up the joint capsule to restore stability to the joint. So now I need to gradually work it back into a functional range of motion.

One of the weirder things about this process is how much my proprioception and joint position sense, my sense of how my arm and joint are positioned in space, is very off. Most of the receptors that send that information to our brain are located in the joint capsule.

I noticed back before surgery that I had a feeling like my insides were shaking or vibrating, like an internal tremor. This started the day of the injury and continued until I had surgery. While I haven’t found a lot of research evidence (or any) about that, my theory is that it was due to my brain being more than a little bit freaked out about the feeling of my shoulder being completely unstable and the capsule being all stretched out. That feeling stopped after I had surgery.

Now that the joint capsule as been tightened up my brain has not yet relearned how to interpret this joint position information from these receptors in their new, surgically-modified positions. This position where I’m lying on my back and my forearm essentially points straight up to the ceiling is considered 0 degrees of rotation.

Zero degrees rotation with cane — About 0 degrees of shoulder rotation.

But when I close my eyes it absolutely convincingly feels like it is at at least 50 degrees of external rotation.

50 degrees of shoulder rotation. — About 50 degrees of shoulder external rotation.

But then I open my eyes and see that first 0 degree view. It’s the oddest thing.

It’s not quite as disoriented with shoulder flexion as it is with rotation. This makes sense because external rotation stretches out the anterior joint capsule more than flexion. The anterior joint capsule is the part that had to go through the most stretching out from the dislocation and subsequent tightening for the repair. Still I had my husband take this photo of me working on a table slide flexion exercise so that I could see how the joint angle is coming along because I’m not totally sure how reliable my joint position sense is for this plane of motion either.

Most of what I work on with my patients is related to this concept of proprioception. I specialize in finding ways to get the best information to a patient’s brain from their muscles and joints so that they can then have the best, most efficient output coming from the brain to the musculoskeletal system, then back and forth that conversation goes, hopefully with a higher and higher quality of information. This is giving me a close-up experience with relearning this after a significant reorganization! The neurological system is so cool.