16 month update

We're a few days early on this, but I wanted to get some additional information down that I forgot to post at the 1-year update concerning scapular stability. I was working on this primarily in my second go-round of therapy during months 8-12 post-surgery when I started having elbow pain following my premature exit from initial therapy. As it turns out the scapular control has been really great for my throws during Ultimate, especially the backhand. This is timely as Jonah Wisch, a former team mate, just posted an article talking about this very topic.

Before I get into it, I just wanted to give an update on my condition. The shoulder feels really good. I can barely tell I had the surgery anymore other than the scar and a few awkward overhead arm positions where I still have some minor stiffness/weakness. Interestingly enough, I was really scared to get back into climbing, especially after the elbow problems from this past late summer/early fall, but as it turns out, getting back to climbing was the best therapy I could've done. There are so many dynamic aspects to climbing involving not just the grip and forearms, but moreover the shoulders and back muscles. Things that I really had a hard time training statically/during therapy. I started climbing again full time right after the new year, and now, two months later I see a huge increase in strength and range of motion. I'm thrilled with where I am, physically in that regard. I'd say I'm beyond 95% ROM, and in some ways I am better than I was before the surgery because 1) my tendons aren't ruptured anymore, and 2) I have much better scapular control, which of course is the focus of today's post.

Details on the therapy are found in earlier posts, but there are the actual therapeutic procedures and exercises I did to deal with my scapular control issues, elbow pain, and shoulder hypermobility.

-Prone horizontal abduction on physio ball, 3x10


-Wall walks/slides, x15 (can be done w/theraband connecting both wrists)


-1/2 foam roller (balance) quadruped ball roll, 3x30s
See image: can do this with just one half-foam under knees, adding the one under hands makes it harder. Image shows arm extensions, but can be done pushing/batting  ~8lb medicine ball around on floor next to support arm/under shoulder


-1/2 foam roller (balance) frisbee backhand (mimic throwing motiona w/o releasing), x30
Stand on half foam as shown in image, or switching feet parallel to length of 1/2 foam. Go through throwing motions with frisbee. Can work on actual throws/catches if you have a partner.



-Foam + CLX band resisted frisbee backhand (CLX band attached to arm/shoulder and anchored to stationary object i.e. squat rack), x40
See image: For using a disc, just change angle of arm/attachment to adjust for backhands.


-Side laying, solo one-handed (external rotation), 1lb ball toss, external rotation, x30
This can also be done, as this video shows, as a dumbbell lift
See image: Replace dumbell with small 1-2lb medicine ball and do quick short self throw/catches using same hand-position/range-of-motion shown, here.

Upper panel image

Lower panel image

-Side laying, partner toss one-handed (over-handed), 1lb ball toss/throw, x30
^Same as above side-laying exercise but have partner stand ~5-10 feet away and underhand toss medicine ball, which you catch in the position from lower panel image and throw back. Stabilize with scapula!

-Sustained dumbbell scaption, balance on 1/2 foam, x20

-1/2 foam 'statue of liberty' w/red theraband flex bar, 4x30s





-1/2 foam quadruped 'thread the needle', x20 (Video shows motion, but try it weighted pulling on cable machine)
Alternate video, added difficulty from side plank: thread the needle', 20lbs x20


-Standing external rotation w/theraband, 3x20
I prefer the "no money" variation, which forces each side to pull equally.



-CLX band plank walk/crawl, 3-5 steps in each direction x3
Couldn't find the perfect photo/video, but it can be done similar to the resisted bear crawls (sorry for the music). CLX bands have infinite applications and are easy to travel with. Awesome when you're on the go, or traveling to tournaments.

These two images are both showing great exercise variations. The first one, instead of done standing, but in a plank position and walking sideways (crab walk) or forward/backward similar to the resisted bear crawl video is awesome and VERY tiring.






-Standing ball dribble off wall at 90degrees/90degrees (elbow/shoulder), 3x30s
Make sure to keep that angle at 90 degrees both at the armpit and elbow!


Many of these exercises can be made harder/easier by removing/adding a balance ball, bosu ball, half-foam, or standing on a single leg, attaching a resistance band, etc.

This may be my last update so thank you for hanging around and checking everything out of the last 16 months. The shoulder feels great. Now I just need to figure out this lower lumbar/spine issue. Appointment on March 8th. Fingers crossed for a no-surgery solution!

What change a year can make

Hard to believe I am 365 days removed from surgery. At this time a year ago I was trying to struggling to eat dinner, my nerve blocker had not worked off, so I couldn't feel my fingers in my right hand, and I was woozy from the anesthesia. That night was one of the worst of my life, particularly the gap between surgery pain killers and the oral opioids that had not kicked in, yet. The following weeks were no easier.

My last entry was four months post surgery, in early March. I was released from physical therapy rather quickly to home exercises. It turned out to be a mistake. What most of you do not know is that in the months following I did continue to make progress in strength and range of motion, but most of my technique was sub par. I was compensating with my trap for my scapular controllers. My supraspinatus still wasn't firing correctly. As a result I started putting more strain on my triceps and developed bad elbow pain that I initially thought was some sort of lateral or medial epicondylitis (golfers or tennis elbow). By the 4th of July I could barely throw a backhand without terrible sharp pain. I was terrified I had torn something in my elbow because of compensation issues. I had to do something about it, or risk long-term health issues, and ruining my Club Ultimate season. On July 16th I went back to physical therapy.

Though I tried to return to the same office that was involved in my procedure, they made it difficult to do so based on their silly policies and lack of available appointments. I went to a different office that took me almost immediately. Physiotherapy Associates (Rockville office) has taken incredibly good care of me in the past nearly four months. From the front desk (Cindy), to the therapy assistants (Erika and Brian), to my therapist (Anastasia Rukavyshnykova, yes, Nastia, I did it without checking your business card), I received nothing but the highest standard of care, met with a willingness to work with me closely, and a true empathy for my situation.

I will post a scanned image of all the exercises I have been doing in the past four months, but until then I simply want to share the diagnosis. Turns out I have substantial joint hypermobility, including at the elbow. Essentially, I am able to extend knees/elbows beyond 180 degrees, I can bend my fingers back to abnormal degrees, etc. As a result of this, and combined with substantial weakness in the external rotation of my shoulder the problem with my elbow developed. With external rotation of the shoulder, primary muscles involved are teres minor, deltoid, and infraspinatus, that later of which was the other tendon that was (50%) torn. Scapular control (muscles in the mid/upper back around the spine) is also incredibly important to stabilize many shoulder motions, and this was one of the muscle groups most affected by atrophy during the 6 weeks of non-use post-surgery.

At my four month update I wrote that I thought I was close despite the average recovery time taking about one year. I laughed when I looked back and read that. I set high standards for myself, but I also really believed that I was close. I never appreciated just how complex the shoulder is, nor did I understand how severe the initial damage in my shoulder was, or the fact that the tendons probably were torn and getting worse for the better part of two years before the surgery. The weeks of immobility and passive motion post-op were a big delay and not only was I not getting stronger during this time, but I was getting weaker from non use.  When you consider all these things and add on my hypermobility, plus my quick return to Ultimate and lifting, it is much less surprising what happened to me in July.

So where am I now? For real? I hesitate to say "close", as I did with folly 8 months ago, but I'm in much better shape now. I have more strength and range of motion in all directions. Everything I do now is easier. I think about my shoulder less, though it is still a constant presence in my day-to-day life. The work I did with Anastasia has been remarkably effective, though. The elbow pain went away within a few visit. My strength, particularly external rotation, is finally improving as I stay as diligent as possible with my at home therapy. My scapula on the right side actually feels like it is activating, when I felt like I could not will it to 'go' for months after the surgery. It feels like a real muscle again! More great news is I'm back to lifting heavy. Last week I hit 205# on my squat and 365# on my deadlift for the first time since my surgery. Most importantly I can bench press (flat and incline) safely, comfortably, and without and searing pain in my shoulder. My next goal is to hit 1000# on these combined lifts. Ultimate is good, too. My pulls and deep throws feel good. The mechanics on my hammer are returning. I have not returned to climbing, and I'm not sure when I will, but that is currently less pressing that making sure everything with my shoulder and elbow is totally fine. For now, everything is moving forward, and I feel good about that.

The plan going forward to is to keep working hard; remaining diligent; remaining mentally tough. I had a lot of moments of psychological and emotional struggle in the past year. There were many times that no one is aware of, until the moment I publish this blog post, where I completely broke down. It always happened during a shoulder workout. I would be stretching in the doorway, working on front raises, or my scapular control, and looking in the mirror I could see my form was awful. I would get frustrated. "It's nearly a year since my surgery, why can't I do this? What is wrong with me? Will I ever be ok?". I'd feel my elbow pain come and go, occasionally. I would often feel completely helpless. I would hang my head, or even lay no the ground in a crumpled mass of frustration and cry.

So, this year was hard. While I wouldn't wish this experience on anyone for many reasons, I can appreciate the character building that has come from my struggles, and I am sure in the months and years to come I will look back on this time much differently. For now, I am happy to be nearly through the muck.

Four month milestone

Today is four months since my surgery. Let us celebrate with some awesome quick hits.

-I had my last physical therapy appointment, yesterday. All on my own for the last bit, now.

-I have been officially cleared to return to playing Ultimate. I'll be back on the fields before the end of the month (Spring League & Fools Fest!)

-My range of motion and strength was tested, and they both improved greatly since my three month follow-up. I'm at nearly 100% of 'normal' ROM, and my strength is good or better in all planes of motion, though my external rotation is still the weakest of all.

What it all means is a lot of the questions marks are gone. I'm lifting heavy in all non-shoulder lifts, though still progressing to gain back the atrophied muscle on my right arm side. I'm in pretty good cardio shape, as I've been running/training since just before the New Year. Still the question remains if my throwing mechanics will be negatively impacted long-term, but given what I'm able to do these days, I'm much less concerned about this.

I still have about two months of hard at-home rehab to do to smooth out the edges of my motion, flexibility, and most importantly my strength, but I anticipate that by the time the calendar hits May 1, I'll be as good as new. FWIW, the average 'full-strength' recovery time for this procedure at my level of damage is closer to one year.

Huzzah!

100 days

Today marks 100 days since my reconstructive shoulder surgery. What a journey it has been, so far.

In the beginning I struggled mightily, slept very little, and was largely uncomfortable nearly all of the first month. Each step forward seemed huge - first rehab session just 48hrs after surgery, stitches out after two weeks, sling off in less than a month. I also progressed rapidly through my first 10 weeks of physical therapy, quickly moving from passive to assisted to active range of motion. Those sessions were painful and difficult, but I was motivated by the thought of returning to strength and health, and I was driven by my own desire to stay ahead of the rehabilitation timeline. There were low moments and frustrations, but the progress always kept me mentally afloat.

The past month since I posted my last update has been frustrating for different reasons. It was not so much pain, or stiffness, but what appeared, for about two weeks or more, to be a complete stall in any progress. I could move my arms above my head, but the shoulder sat awkwardly above the socket, as if it were frozen in a right shoulder shrug. Beyond this, I was still very weak from the time in the sling, and had lost 5-7 pounds of muscle, mostly from my right arm, and the right side of my back. My scapula, teres, and other back muscles weren't firing normally, as if I couldn't make the connection from my brain to make them go when I needed. As a result, my shoulder blade was 'winging' badly, flying outside of its normal plane of motion in a strange compensatory way. I was running and doing agility workouts pain-free, but when I went to throw a frisbee, all my forehands were blading straight into the ground about 10 yards in front of me. I had gained back so much flexibility and range of motion, but the last 10-20% I was missing was completely destroying my form. For the first time since the surgery I worried that I would never regain my ability to play high level Ultimate, again.

Despite my fears, Lita remained encouraging and kept pushing me. She is a therapist not only skilled with her hands, and knowledgable about the body, but adept at reading emotions and understanding the psychology of an injury and the recovery from it. With her help, I made it through the last four weeks.

I'm not sure if stalling in my recovery was a normal part of my healing, or if perhaps I went too hard on strengthening (once I was cleared for it) while falling away from the stretching and range of motion activities. Either way, it became clear at my three month follow up with my surgeon (nearly two weeks ago) that both range of motion and strength were good, enough so for a normal day-to-day life, but not so to again be 100% as an athlete. To achieve this I needed to work even more diligently to regain the last bits of my function and power. Interestingly, my internal rotation ROM was about 30 degrees behind my external rotation, but my external rotation was the far weaker of the two. Although this is to be expected since external rotation puts the most strain on the repair site for the supra- and infraspinatus tendons, there was too large of a gap between the ROM and strength in each direction. Interesting physiological note, as you gain motion in one direction, you usually lose some in another, which is especially true of baseball pitchers. Typically the total ROM is 180-190 degrees.

External (ER) vs Internal (IR) ROM

My new regiment, since the three-month follow-up has brought in a few new exercises and modifications of old ones with the aim of increasing both flexibility and strength in all planes of motion. I've been very diligent, and I have seen the returns on my time investment. My internal rotation ROM has improved and is nearing equality with my left side. Also, last night I got my supine overhead ROM to where I can put the inside of my elbow joint up against my ear AND have my forearm touch the ground. Try it, you can do it, but think about not being able to for 100 days!

I've also noticed increases in strength, particularly in the problematic ER plane. Combined with my IR ROM, these two factors will be critical for generating power and achieving proper form on my forehands when I return to Ultimate. I'm working through some eccentric training (negatives) using Therabands, which have proved highly beneficial. Also worth noting, I've been cleared to do all weight training except overhead lifting (maybe another month on that), and although I've avoided it, I am cleared to do some roped climbing, too.

With the adjustments I've mentioned, it's clear I'm back on track. I may have written this before, but I can actually feel the end coming, now. I'll be cleared to play Ultimate again in the next 4-6 weeks, by which time I will be about 20 weeks out from surgery (half a pregnancy!), though full strength won't return for probably another month after that. Unreal. The shoulder really is complicated and while hard work is important, so too is patience. Lesson learned.

Can't wait to see you on the field!

10 weeks!

To my dozens of fans and committed readers, I thank you for making it with me through TEN WEEKS(!) of rehab. At this point, I'm ready to start throwing a Frisbee 10 yards with a partner (call me!), and I'm hoping to be climbing by February.

Lita and I decided that because of my rapid progress and most especially my diligent attitude toward my rehab, it is ok to move to one PT session per week. This lightens the load on my wallet, opens up more time at work (I'm back to kicking ass full time without any issues as I do my lab work), and saves my precious insurance-paid PT visits just in case I need them down the line in 2015.

Upon reading the literature on these shoulder recoveries (see earlier posts for these papers) and knowing how my body feels relative to those reports, I believe I am in the final phase of my rehab, which normally is considered to be the 12-16 week period, so again, a bit ahead of schedule. Certainly, I will continue to work hard during the 4-6 month post-op period to build more strength, but I am very close (~1 month?) to reaching the end of my traditional rehab including visits to the therapist's office.

Lita is still holding me back from working my biceps/triceps even though this is typically acceptable at this point in the process, simply because she doesn't want me building any bad habits as far as my motion is concerned. A reminder, the surgery happened 10 weeks ago, but the injury and bad compensatory habits, started years before. We want to rebuild my arm better than ever, and I love Lita's mix of I'm-gonna-kick-your-ass-and-work-you-hard balanced with a be-safe-here approach.

I am just nearly squatting my body weight again, starting light deadlifts, and adding weight to my shoulder lifts (i.e. 8lb prone rear raises, 3lb prone side raises, 2.5lb standing 45 degree raises). A note about my 45 degree raises, Lita started a new manual technique this past Friday do get my shoulder to slide down into the glenohumeral joint, which has helped me with this exercise. No longer does my right shoulder pop/stay up when I lift my arms to the side. The motion is still a little disjointed, certainly not smooth, but the form is there. I should include a picture of this, but it may be too late to capture the previous poor ROM/form.

Just one fully new activity, this week, prone overhead lifts. They are challenging and I can't quite get my arm straight out above my head; as I straighten it, the arm slides out to the side a bit.

Prone overhead lifts

I did advance some of the other motions a little further. My hand is just about getting to the wall in the standing posture exercise. Also, I'm now doing my side plank from a "standing" position instead of from my knees.

"Standing" side plank

You get the idea.

Can't wait to post the next update which will be 12 weeks post-surgery, and leading up to my 3-month follow-up appointment with Dr. Berdia!

Eight weeks down & we're rockin'!

Since week six I have made a substantial amount of progress in my rehab, but since the milestones are further apart, I'll likely only post updates biweekly, now. Here are some cool things I can do which most people, myself included - at least pre-surgery, probably take for granted.

-I'm sleeping on my repaired side, although I can't tuck my arm in yet. I still leave the arm extended and outwards, away from my body.
-I can now comfortably reach past my left shoulder with my right hand.
-I can dry my back after a shower by holding a towel behind me and pulling back and forth.
-I can reach up with my repaired arm and grab the top of a door frame, unassisted.
-I can throw a frisbee, backhand & forehand, about 5+ yards! (Heather and I tossed this past weekend. I got about 25 throws in before my arm got tired!)
-I am allowed to back squat with the bar (up to this point I wasn't able to even get my arms back behind my head comfortably to hold the bar in place). Worked up to sets of 135 and felt good.
-I am allowed to carry weights in my right arm, now; arm by my side, hanging, only. This is useful for doing weighted lunges and similar lower body exercises.
-My warmups for therapy no longer start with a heating pad, but on the hydraulic arm bike!
-I am doing strengthening exercises with bands and weights now (See more, below)
-I got a parachute for Christmas and am did a kick ass sprint workout with it, last weekend! I'm also getting my cardio fitness back up. I've worked up to eight minutes at ten m.p.h. on the treadmill (~1.3mi).

And now onto the details, if you feel so inclined to read on.

My overhead and external ROM are 80-85%, and that last little bit is in sight. I started this exercise to get over that last hump of stiffness.

In addition, when I get to the top of my ROM I slide over into the door frame forcing my arm up further. By forcing into the door frame, I can also push my lats & teres muscles back into my body, stopping them from (chicken) 'winging'.

As far as ROM, my internal rotation is also getting much better, and I can do this now.

The winging I mentioned above is already much better as I have already gained considerable strength in my teres/scapula from doing weighted table work. From the position in the first image shown, I have worked up to 3 lb. underhand raises (lifting weight in plane with my body, fingers pointing towards my feet), which hits the rhomboids (image 2), and 1 lb. side raises, hitting the deltoids/shoulder and scapula (image 3a). The added motion with the side raises is to get the thumbs pointed as much as possible up towards the ceiling (image 3b), with the idea of helping rotation within the shoulder joint, which I only have about 50% ability to do.

Image 1 - base position

Image 2 - underhand raises, rhomboids

Image 3a - side raises, deltoid, scapula, shoulder etc.

Image 3b - thumbs up!

More scapula work includes Theraband/tube abduction, and rows.

Abduction

Rows

I'm also working on postural strengthening. This exercise requires a tight core, and arms, elbows, shoulders, back, butt, all against the wall. The trouble I'm having is even though my external rotation in a supine position has reached 80-90 degrees, there is still stiffness in the joint, and full ROM requires assistance by pushing the arm out in that plane of motion. Actively moving my arm against the wall isn't yet possible. Note: I haven't started doing wall slides in the way shown below, yet, although my standard wall slides are becoming much easier and I can now almost fully keep my arms parallel as I do them!

Postural strengthening (left image)

Modification with upward wall slides (right image)

Supine external rotation of the shoulder. When I do my postural strengthening against the wall, this is about as far as I can get my arm, so far.

One of the harder things I am now doing is a side bridge to strengthen the teres major which should help immensely with my aforementioned 'winging'.

Side bridge                                        Teres major

Finally, I'm doing, for lack of a better term, what we call a table lean. The image below is actually meant to demonstrate single-armed incline pushups, but it's the closest thing I could find to what I'm doing. Essentially, I start with both arms on the bench/table/chair in front of me, and alternate between balancing in the 'up' position of the incline pushups, which I'm also using to target the teres, stabilizing the shoulder, but also requires pectoralis, core, and even some groin/glute tightening. What the image doesn't show, is that sinking the hips into the table is required, and the closer the feet are together, the harder this gets to hold.

"Table leans"

So the verdict is, after eight weeks, I'm well into phase III (strengthening), again, ahead of schedule. I'm sleeping better. I feel good. I'm doing sprint workouts now! Everything is doing great on this last day of 2014, and I am excited for 2015 to start. 

Happy New Year!

Six weeks in the books

Few new exercises, which I'll get to, but the long and short of it is: I remain ahead of schedule! Here is a great resource with a clear timeline for rotator cuff repair.  I continue to be at or slightly ahead of the earliest described timepoint for all activities.

Day-to-day improvements:
-I can fully reach my right arm across to my left shoulder, which makes showering and dressing nearly thoughtless activities, again. This resulted, I believe, mainly from the progression of passive activities the therapist is putting me through, laying me on my side and stretching the repaired arm across my body (towards the floor).
-I can put the key in the ignition of the car, and put the car into gear all unassisted with my repaired arm.
-I can put weight onto the repaired shoulder, i.e. when shifting in bed at night, or pushing myself out of a chair/off the floor.

This week we moved into isometric activity in several planes of motion, including adduction, abduction, that is, internal and external rotation, both from the wrist (shown below) as well as abduction from the elbow into the wall. I am also pushing my fist straight towards the wall, and my elbow back into the wall. In addition, I'm doing a full cohort of AAROM with a broom stick as a great warm-up.

Isometrics (top two panels)

"wand" exercise (middle panels)

I am also using a lacrosse ball to work out knots in my shoulder (from the front and back), simply by placing the ball between my shoulder and the wall, and leaning into it, massaging around, etc.

As long as all these additions, particularly the isometric work, go on without a hitch, I will be allowed to continue intensity and frequency and move towards resistance band training, soon!