Shoulder

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.

February 11, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 10 — Tips for daily life with one functional arm

First a status report! Things are progressing very, very frustratingly slowly. I’m still struggling with pain management. I’ve used up the Percocet that I was prescribed right after surgery. I could request a refill from the doctor but given that it was only marginally effective to begin with I’m switching to acetaminophen (Tylenol). I still have gabapentin and Flexeril, but again, I’m not sure how much those are doing for me other than making me sleepy so I’m only taking them at night. I’m pretty much using the cold therapy machine, which circulates icy cold water through a pad I strap onto my shoulder, constantly except for when I’m doing my PT homework.

Speaking of PT homework, that’s also frustrating as my motion is extremely limited. To be clear, that’s what we want because the surgeon tightened up my shoulder joint capsule so that it will be stable when all is said and done. But at the moment I can only move it maybe 2 degrees into external rotation and even that tiny motion is very painful. I also can barely shrug my shoulders up toward my ears and even that simple motion is also very painful. So very frustrating! On the other hand I finally got back to acupuncture for the first time since surgery yesterday and actually got a full night of sleep last night for the first time in 2 weeks, so I’ll take that win!

Since I dislocated my shoulder on January 14th and continuing after surgery on February 1st I have had to keep my right arm supported in a sling. Even though it’s my shoulder that’s actually hurt using my right hand is challenging too. That’s because most of the things we use our hand for require stabilization and rotation from the shoulder to get the hand in the optimal position and at the best muscular advantage to complete the task. As my patients like to point out to me, I always say everything is connected. We joke that I should get that painted on my wall so I can just point to it all day. If your shoulder can’t work correctly neither can your hand. (This is also a great illustration of how if you have a hand, wrist, or elbow problem the underlying problem might be a lack of stability and strength at the shoulder!)

Some of the things that are difficult to do with one hand are things that, before this experience, I wouldn’t have even thought about how they’d be affected. In researching how to do things with one hand many of the resources I’ve found are for people who have had amputations or were born with congenital limb differences. These modifications generally use the residual limb to assist with the activity. In the case of an injury like mine you can’t really use the injured side to help at all. So for an injury like mine the modifications are necessarily different and temporary.

I’ve found some good tips and tricks that might come in handy for anyone who, like me, is temporarily unable to use one arm for daily activities due to an injury. Of course for me it’s my dominant hand, which just complicates matters even more!

Handwashing is always essential, but especially important during a global pandemic! It’s challenging with one hand because you can’t use the friction of rubbing your hands together to soap up all surfaces of your hands. What I’ve used to solve this problem is actually meant to be used on the floor of your shower to help you wash your feet. I have it suction cupped to the side of my sink. I get some soap from a pump dispenser in my left hand and then use this to lather up my functional hand.

Foot brush used for single-hand handwashing — I’m using this foot brush scrubber for single-hand handwashing.

Dental flossing with one hand is pretty much impossible as far as I can tell with traditional floss. I’ve been using these flossers to keep up what any dentist will tell you is an essential dental hygiene habit even though I can only use my left hand. I also recommend an electric toothbrush, especially if your functional arm is your non-dominant side. That way you can make sure you are still doing a good job of brushing even though you’re using your less coordinated hand.

Flossers for single-arm dental hygiene — These are the flossers I use to keep up with flossing with one hand.

Washing dishes is difficult with one hand mostly because you normally use one hand to hold the dish in place while you scrub with the other hand. In my case, my husband has been doing most of the dishwashing. We also have a dishwasher so things that can go in there I can just rinse and put in. But sometimes I just want to wash a dish myself or I want a pan or something that can’t go in the dishwasher and I don’t want to bug my husband to do it. After all, he needs to work since one of us needs to be earning money right now! So I got this nonslip mat for the bottom of the sink to hold the dish relatively still while I scrub it with my left hand. I’ve also seen suggestions to use a hammock-like netting across the sink so that the weight of the item being washed holds it still in the fabric hammock. I figure this nonslip mat will be more useful for us in the long run as we can keep using it even after my shoulder recovers. We also have a sprayer on our sink which I’ve found essential for directing higher pressure water where I want it for rinsing.

Non-stop sink mat for washing dishes. — This is the non-slip sink mat that I got for washing dishes.

Staying warm in the middle of winter while wearing a sling is a challenge. This one is admittedly more about wearing a sling than about having one arm to use. Because of the sling I can’t just slide my right arm into a coat. I also can’t really zip up a coat by myself since that’s another thing that you have to stabilize with one hand pulling down while you pull up with the other hand. Luckily ponchos are in style right now. I even saw a hooded, faux fur-lined poncho for sale. I didn’t get that one though as it was a little beyond the price I’m willing to invest.

Hooded poncho for staying warm — This is the hooded poncho I ordered to wear when I have to go out in the cold.

Also, someone gave me this awesome thing as a gift. The Comfy is basically a giant hoody made out of a fleece-lined velour blanket. I can put The Comfy on over my head and put my left arm through the sleeve and just let the right sleeve dangle empty while my right arm stays in the sling inside it. This thing is super warm, cozy, and big enough that it’s not hard to get it over the sling.

Me in The Comfy — This is me taking a selfie in The Comfy, which is basically a giant hoody made out of a fleece-lined velour blanket. So warm and cozy!

Typing on a computer has been difficult for me. This is something I wouldn’t have thought about before this injury. You would think if it’s just my shoulder affected that typing should be one of the few things that I can still do without any modification. But it’s actually difficult for me to get my right hand turned forward in the right direction to face the keyboard correctly. They do make keyboards that are separated into two pieces, one for each hand, so that you can have your hands in different orientations to the keys. But that’s not an investment I want to make since, as slow and frustrating as this recovery is going to be, it’s not a permanent situation. Also, even if I had the fancy separated keyboard it’s still difficult for me to pronate my right hand (turn it palm down) to type because again, any rotation at the forearm, wrist, and hand doesn’t exist in isolation from a corresponding rotation at the shoulder joint. Therefore, as tedious as it is, I’ve been using my phone to type and also using the voice-to-text feature whenever possible. The phone keyboard is small enough to be used with one hand or with two hands without any pronation of the right arm required.

Typing on my phone is easiest — Using my phone to type things like this or using the voice-to-text feature is much easier than trying to use a computer keyboard.

There are a lot of assistive devices out there to help with doing all kinds of activities of daily living with one hand. Most of them are things I would only get if this was a more long-term or permanent situation or possibly if I lived alone and didn’t have a good support network of folks to help me. For example, just like with washing dishes, cooking is difficult because you would normally have one hand to stabilize the pot while you stir with the other hand. There are pot stabilizers you can get to help with that. There are also food prep boards you can get that have spikes to stabilize something while you chop it with one hand. Click here for a great resource from the UK’s NHS for all kinds of modifications to make activities of daily living easier to do with only one hand.

If you have questions or other ideas that are helpful for doing daily activities with one hand, send me a message or comment on the post on social media. You’ll find me on Facebook @chppt and on Instagram @collegehillppt.

February 8, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 9 — 1st PT appointment

Today was my first physical therapy appointment. I forgot to take photos so you’re stuck with diagrams of the exercises! Let’s blame it on the meds.

Many people have asked if I plan to just rehab it myself since I am a physical therapist and I normally do treat this type of injury. Sometimes it’s a good idea to treat yourself and sometimes it’s not. It’s true that I usually do rehab my own injuries when I’ve got a muscle strain, a little tendinopathy, or when my shoulders feel a little unstable and cranky. It’s also true that I can figure out what exercises are appropriate at which stage of my recovery. But I can’t do low grade joint mobilizations on myself to help reduce pain and muscle guarding (when muscles reflexively tighten around an injured joint to protect the joint). And I’m not in a position to be able to see and measure the joint angle. My proprioception and joint position sense are TOTALLY thrown off by the injury and reconstruction. So I need another set of expert eyes to tell me where I am. And simply based on the severity of this injury, reconstruction, and rehab I need someone to walk through this with me. Even teachers need teachers. PTs sometimes need a PT.

There is thinking out there that all PT is the same and it doesn’t matter who you see. That PT is PT and all PTs are interchangeable. That couldn’t be further from the truth. As in all professions, you need to choose your PT wisely and if you start with someone that doesn’t work for you, find someone that does. So today I went back to Mt Lookout Chiropractic & Sports Injury Center, where I worked for about five and a half years before I started my current practice, to see my former coworker, Dave. He’s an excellent, experienced PT and knows me well so I feel comfortable having him help guide me through this recovery. This is where I’d normally throw his photo in, but he’s not one for photos, or social media for that matter!

Before PT today I was feeling very discouraged. I was feeling kind of stuck, like nothing was getting better or changing. I’m still needing all the meds for pain management, although I’m only taking the muscle relaxer at night rather than 3 times a day now and I did stop taking ibuprofen. And I still can barely tolerate being out of the sling. I’m still sleeping in a recliner because it hurts to lie flat for too long. I stilñ use the cold therapy unit pretty much nonstop. And of course I’ve noticed my muscles of my right arm starting to atrophy (shrink) from disuse. My biceps looks particularly sad and floppy. As I tell my patients, everyone wants to get better yesterday.

Shoulder external rotation using a cane or wand — This exercise is to begin moving the shoulder into external rotation.

At PT with Dave’s help I was able to start getting it moving. We got it to about 80 degrees of flexion (the goal at this point is 120) and got it to externally rotate a little bit. Even just doing that little bit made me feel like this isn’t forever. I know my shoulder will never be the same as it was. I don’t want it to be like it was, clearly it was too unstable! But my shoulder will be “normal” in a few months, whatever its new normal winds up being.

Shoulder flexion table exercise — This is the exercise I’ll be working on to improve shoulder flexion.

I’ll be working on some exercises a few times a day: shoulder shrugs and shoulder blade squeezes, elbow range of motion, table slides for shoulder flexion, using a cane for external rotation, and some pendulums using a therapy ball for support. It’s going to be hard but it gives me something to work toward. I’ll see Dave once a week for the work he can do with it that I can’t and to make sure everything is on track. As we get it moving some of the pain should start to ease too!

Stay tuned for more on my progress!

February 5, 2021 By Mindy Nagel, PT, DPT, OCS

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 8 — Follow-up

Today I had my first post-op visit with the surgeon. He showed me the scope photos again and said that I now have a very stable shoulder. The amount of damage you can see in the “before” photos is very impressive. He said that the goal over the next 6 weeks will be to get it moving through active range of motion to my tolerance.

The different types of motion are passive range of motion- where someone else (usually a PT) moves it for you, active-assistive range of motion- where you move it yourself with assistance from something or someone, and active range of motion- where you move it yourself. Given the nature of this injury and my hypermobility we want to preserve some of the stiffness created by the surgery so we’ll be going slow, sticking with active range of motion, and not pushing motion too aggressively. According to the orthopedic, the goal at 6 weeks will be to be able to lift my arm to the side to 90 degrees. So slow going.

Stitches off, steristrips in place — Bandage and stitches off, steristrips in place. There are 4 incisions. You can see all but the one in the back here.

I also had my bandage removed and stitches taken out today. I’m super pumped about that because now I’m allowed to shower. Also I can use electrical stimulation and I’ll actually be able to get it cold with the cold therapy unit without that big thick bandage in the way. This will help immensely with pain control and maybe I can get off all these meds.

Electrical stimulation set up — Back home with e-stim pads set up for interferential current for pain relief.

At the moment I’m taking Percocet- an opioid pain killer combined with Tylenol, Gabapentin- a nerve pain medication, Flexeril- a muscle relaxer, and ibuprofen. Since we added the ibuprofen the pain has gotten much more tolerable, but I want to get off that as soon as I can since it delays bone healing. The other 3 meds are making me sleepy and giving me brain fog. So looking forward to decreasing some of that!

I’m feeling pretty optimistic at the moment about my shoulder. So many people have offered to help by bringing meals for my family or doing whatever else is needed. It’s hard for me to accept help. It’s just not in my nature. So this is a good learning experience to accept help when I need it. Also, looking on the bright side, it’s awesome to see people show up for me. I’m also starting to feel glad that the surgery is behind me, instead of regretting it like I did Monday night into Tuesday when I was in so much pain. Now there can be some forward progress in recovery.

I have my first PT visit on Monday with a former coworker. Once again, a privilege of being a PT is that we know the best health care providers!

Stay tuned for the next post where I’ll tell you how PT went!

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

Experiencing a Catastrophic Shoulder Injury from a Physical Therapist’s Perspective, Part 7 — The Surgery

I went in for surgery on Monday as planned. In pre-op a nurse placed the IV and gave me some meds through it. One was an antibiotic and the others were anti-nausea medications since I tend to get nauseous very easily from anesthesia. They also gave me a scopolamine patch behind my ear. This is the type of patch that is often used to prevent motion sickness.

Waiting in pre-op — Me waiting in pre-op with a fancy inflatable blanket. They blow warm air into the blanket at whatever temperature you like. It was quite comfy.

An anesthesiologist gave me a nerve block using ultrasound guidance. He explained that this was actually two different types of nerve blocking agents. One of them was meant to be short-acting for during the surgery. The other was supposed to be long-acting so that I would have two to three days of pain relief from the nerve block itself after surgery. I told the anesthesiologist that local anesthetic wears off very quickly with me if it works at all. Even though I’ve never had a nerve block before I was worried that it would wear off quickly. He said that between the medications he was using and the ultrasound guided placement he was sure that the nerve blocks would work.

After all of that it was really just a waiting game waiting for the surgeon to be ready. I have been very anxious about this surgery and waiting around just amplified all of that. My husband was allowed to come back to the room with me for pre-op, so at least I had someone to keep me company. The surgeon stopped by the room and marked the right shoulder. I was able to talk to him about what he was doing and make sure he understood that no matter what he saw when he got into my shoulder the most important thing is to make sure it never dislocates again.

In the surgical suite I transferred myself from the bed I was using in pre-op to the table for surgery. For this type of surgery they actually operate with you somewhat sitting up in a reclined position so you lie flat on your back on the table and then after they give you anesthesia they sit you up to operate. The surgeon was able to do everything we expected and didn’t find anything extra like any rotator cuff tear or anything that he wasn’t expecting. When he spoke to my husband while I was still in recovery he told him that the labral tear was all the way around from the front side to the back. If you think of the glenoid (socket) as a clock the PA told me the surgeon repaired it from about the 10:00 position all the way around the bottom and up to the 2:00 position. That is called a 180 degree labral tear. So it definitely needed to be repaired The surgery went according to expectations and he said my shoulder was significantly more stable when they checked it after the procedure, which is great!

Arthroscopy photos of my right shoulder — These are photos taken through arthroscopy showing the repairs to my shoulder.

After the surgery my husband spoke to the surgeon who gave him photos from the scope of the inside of my shoulder and basically confirmed that he had done what we set it to do.

When I was in the recovery area I woke up from the anesthesia with significant pain It appears that the “long-acting” nerve block did not do what it was supposed to do which is keep my shoulder numb and gradually wear off over a couple of days to make that immediate post-op pain tolerable and so that you don’t fall off a cliff from short-acting nerve block to pain. Pretty sure I fell off that cliff. So in recovery they gave me some medication to help with the pain. After keeping me in observation for a while to make sure I didn’t have any adverse effects from anesthesia they sent me home with Percocet for pain and Zofran for nausea.

Pain management has been a big challenge. As I said, I’m not sure what the nerve block really did for me. It made my hand and wrist numb and I couldn’t move my hand and still can’t move it normally, but shoulder pain has been severe. I woke up at 3am the day after surgery in terrible pain. It was the same amount of pain as when it was actually dislocated. Ice doesn’t help because the bandage on my shoulder is too thick for the cold to get through.

I contacted the PA, physician assistant, who writes all of the prescriptions for the surgeon. He called in gabapentin to the pharmacy for me. I took it but pain was no better. Next he called in a prescription for Flexeril, a muscle relaxer. But still the pain did not improve. So finally he recommended ibuprofen or Aleve. Technically I’m not supposed to be allowed to take ibuprofen or Aleve for 6 weeks after surgery because they delay bone healing. But he said it would be okay to take them for a couple of days just to get through this acute painful post-op phase. So I took some ibuprofen and it seemed to help a lot. I’m still having a fair amount of pain, but not the screaming pain I was in before. Hopefully now my poor husband can be done running back and forth to the pharmacy!

All of these meds are making my brain slow and foggy. For example it took me much longer to write this than it normally would. But that’s fine. I much prefer brain fog over extreme pain!

I can’t wait to get through this immediate post-op phase. Next step is the follow up with the surgeon on Friday.