I just returned from the orthopedist/surgeon's office. He did a great job assuaging the fears I had about the damaged tendon. It turns out I may have overreacted a bit. I won't be in the sling that much longer than had the injury been a labral tear, and in fact, he feels generally more confident about the recovery for this kind of procedure. The doc walked me through every bit of my MRI scans, showed me the problem, explained it, and reassured me that there are no other problems in the shoulder. In fact the radiologist noted there might be partial tearing of the infraspinatus tendon as well, but Dr. Berdia dismissed this, which is agreement with what Kris said as well.
So the big news? Surgery is scheduled for...Tuesday! Yeah, I'm going to be under the knife (or arthroscope, I suppose), on November 4th, just four days from now. I'll only miss two days of work and will be doing my first physical therapy (PT) just two days after surgery, Nov. 6th! Four weeks of PT will follow, 2x a week of passive motion, no muscle engagement. Active therapy will follow that.
My initial thought about recovery was, 'Can I beat the 6 month post-surgery landmark', which is where full-strength should be reached. The doc thinks I can be lifting heavy weights and throwing a disc again 3 months post-surgery - the beginning of February! This is undoubtedly great news.
So in a way, this prognosis was the best birthday present I could have hoped for. This, matched with my boss's understanding of the situation, I just got done telling her I won't be able to do an experiment for about a month, has made me feel pretty thankful for the good that is being made of a not-so-good situation. Fortunately, the month ahead at work will be focused on preparing for a big Division-wide presentation, anyway, which would have left less time for experiments, even for a fully healthy version of me. In effect I'm not losing that much time at work. I can still think, write, and talk about my science, and perhaps get a few experiments done one-handed with the help of a few friends, here.
One last hurrah, this weekend (MOSH!), and then it's off to the (recovery) races!
Friday, October 31, 2014
Wednesday, October 29, 2014
Confirming diagnosis & reluctantly leaning towards surgery
I was kind of devastated when I found out about the lack of a labral tear and in its place discovered the tendon tear, simply because of how much more complicated the procedure and recovery will be. In fact, the emotions I was dealing with were probably the main reason for starting the detailed log of my process, because I realized other athletes will go through this and hopefully benefit from my research and experience.
Ok, so the doctor at the imaging facility wrote the report I quoted from in an earlier post, diagnosing the anatomical problem. I also requested to have digital copies of the report and the images, which I showed to a friend who is a hand and shoulder surgeon. It’s always good to get an extra set of eyeballs on your images, no matter what your situation. Sometimes a doctor is looking so hard for one thing he expects he may miss another, I’ve done the same thing as a scientist in the lab with my data. It’s not a disrespect to the orthopedist to ask another one what he thinks, too.
On Oct. 29th, I received an email back from our friend, a hand and arm specialist who trained at the Mayo clinic. He is excellent, but back in Philly/Lehigh Valley and thus too far to be my surgeon on this one. Here is his email reply:
***
Peter.
I reviewed your MRI scan and the report. I agree that you have a small full thickness tear of the supraspinatous tendon of your shoulder. I do not see a SLAP tear (labral tear) and agree with the radiologist as well with that account. The fact is, with these tears, we know that they tend to enlarge with time. As a younger guy, if the tear is causing pain and discomfort, not allowing you to do what you want or need to do, there is a good reason to fix it and get it over and done with. The surgery is done arthroscopically, but takes a good amount of time to heal (6 weeks in a sling and then rehab - 3-4 months average). The other option is to try therapy to make it better. Therapy will not fix the tear, only surgery can do that, but it may make it asymptomatic. The tear, while it may become asymptomatic, may enlarge with time becoming more problematic to fix in the future.
My take on it to patients - partial tear or tendonitis - rehab +/- injection.
Full thickness tear in a younger, active individual - fix it if it is painful.
Full thickness tear in an elderly person - rehab.
I hope this helps. If you want a second opinion or another guy, I have one in Bethlehem, he’s very good. Let me know if you need anything else.
Kris
***
I feel utterly deflated hearing this. I spent a good portion of today not working, but instead obsessing over my diagnosis, hoping I’d find something on the web telling me about some crazy bovine-sperm-derived-growth-hormone method of speeding up recovery. Of course, I didn’t find any such thing, in fact a study shows that HGH doesn’t do anything to help rats over placebo, and can also negatively impact tendon repair at the point of bone attachment. And now, Kris’s email confirms what my research shows. Six agonizing weeks in a sling, 3-4 months of hard rehab afterwards.
I did find one person who logged some of her experiences with recovery from rotator cuff repair, although she *also* had a SLAP tear and some other minor issues discovered once the surgeon got inside. Essentially the extra problems made the recovery significantly longer. She is an amateur volleyball player and fellow climber.
I am remaining optimistic that my high baseline strength, youth, dedication, and stubbornness will lead to a rapid recovery, although I’m not sure there is much I can do to speed up the original 6 weeks in the sling. We’ll see how well my body handles this. Still have to meet with the actual surgeon.
What I know about the surgery, so far
So the best way to deal with these tears is by surgery. You can live without the repair, as I have demonstarted for the past who-knows-how-long, but to really return to the highest level of function, especially for an athlete, there doesn’t seem to be much other option. The surgery is most successful, with tears that occur 1) in patients 35 or younger and 2) following an acute injury, like the one I described happening to me (layout). There’s a whole host of literature on chronic issues, degeneration with aging, etc, etc, but I won’t get into that. If it tickles your curiosity, again, a simple internet search will reveal tons of information.
The main complications with the procedure (assuming the deltoid does not need to be detached) are shoulder stiffness, and inability to return to full strength. I don’t quite understand the full medical side of this, but then again, based on the literature I scoured, I don’t think the surgeons are 100% clear on it either. Suffice it to say, as I mentioned earlier, the tendon doesn’t get tons of blood flow, executing a correct and tidy reattachment is not trivial, and while younger people are more successful at coming back strong, they are also the most likely to re-tear because they will be returning to the athletics that cause the injury in the first place. Stress for post-operative stress is placed on a high baseline strength prior to the surgery, a strict approach to the instructions of the surgeon (i.e. adhering to necessary rest times), and a regimented adherence to the physical therapy once (~6-8 weeks post-op) active motion is allowed to resume in the shoulder. Disclaimer: any time line I provide is from my own experience and should be used as an idea. Your guidelines from your orthopedist and therapist are key in proper healing. They say not to use your shoulder for 8 weeks? Listen. Please.
Some details about anatomy
The suprasinatus muscle is part of the rotator cuff complex. The tendon connecting this weak muscle to the bone is more problematic to fix, although newer arthroscopic methods have helped decrease recovery time. (It used to be that you’d need to have your deltoid detached during open surgery to access the tendon, but now that can be avoided in most cases). The bad news is the recovery is more in the 6 month range, and full strength may not be restored (i.e. heavy shoulder lifting) for up to and past 1 year. Apparently, this tendon is much less vascularized than many others, is slow to heal, and the technique of sewing the tendon back together and attaching it back to the bone combined with the low amount of blood flow leads to a longer recovery time.
A full-thickness tear (as opposed to a partial-thickness tear) essentially means that there is a hole in the tendon. Some piece has pulled away from the bone but it hasn’t completely ruptured/detached. If that were the case the muscle would have rolled up under my clavicle. Some smaller tears may resolve with rest and therapy, but the full-thickness tear will not. Structurally speaking, the muscle is pulling at the tendon from both pieces of tendon on either side of the tear. That tension along with the size of the tear make it impossible for self-correction. There is some evidence emerging in Canada and the UK about using stem cell injections to encourage regrowth of connective tissue, but it is not approved here in the States.
MRI arthrogram: procedure and experience
On Oct 28th I got my MRI arthrogram done. Here’s a summary of the technique:
The right shoulder was examined with ultrasound for anatomy and landmarks. Using sonographic guidance and sterile technique, 10 cc of dilute gadolinium (contrast molecule) and xylocaine (numbing agent) solution was injected intra-articularly using a 25G needle (that’s a pretty small needle, don’t worry). The shoulder was lightly exercised and MRI of the shoulder was performed, consisting of axial, oblique sagittal and coronal FATSAT T1W and oblique coronal T2W images using a dedicated shoulder coil on a superconducting high-field magnet.
The whole process took about an hour, although the 5 scans took 2-6 minutes each; I was only laying in the machine for about 20-25 minutes - pretty simple. Here’s where the news was good and then worse. If you want you can skip the paragraph below with the details and go straight to the summary:
Findings: There is no extravasation of contrast into the subacromial/subdeltoid bursa. However, coronal T2W images show a 6 mm full-thickness tear in the distal supraspinatus tendon near the critical zone, this likely represents a small contained a full-thickness tear with scarring. Small partial-thickness articular surface tears are also seen in the distal infraspinatus tendon. The subscapularis, teres minor and long biceps tendons remain intact. No labral tears or paralabral cysts are demonstrated. There is no focal cartilage defect or intra-articular body. There is mild acromioclavicular joint hypertrophy and a laterally downsloping type II acromion. There is type II insertion of the anterior joint capsule. No rotator cuff muscle volume loss is demonstrated.
Summary:
- No evidence of labral tears. Yay!
- I have a 6mm full-thickness (the full way through) tear of my supraspinatus tendon. Boo!
A turn for the worse & diagnosis
Around Regionals it was apparent that something was not right. Not only were my pulls shorter than they had been, but long hammers started to hurt again, and I noticed similar pain in my shoulder (biceps tendon? rotator cuff? labrum?) while pulling. Two weeks after Regionals I was still playing pickup and Fall league, and started having a hard time sleeping and the pain was more constant than it had ever been before. I reasoned that I had not only reaggravated the shoulder injury, but that I somehow had made it worse, although this time I couldn’t remember having an acute moment (i.e. crooked layout, pull) that was associated with intense pain.
On Oct 22nd I went to the orthopedist who listened to the symptoms. An X-ray showed nothing major in the shoulder except some impingement (trouble rotating the ball/socket joint) but this was not considered significant. The doctor suggested I likely had a S.L.A.P. tear - superior labrum anterior to posterior (http://en.wikipedia.org/wiki/SLAP_tear), and ordered an MRI be performed. I was hopeful because finally I had an answer to my years of pain and decreased strength. All I needed was an MRI to confirm, and then could get the minimally invasive arthroscopic procedure to correct the problem. The recovery looked to be about 12-16 weeks for SLAP tears and then heavy training could resume. Looking ahead I figured I could be playing Ultimate again and doing heavy weight training by the Spring of 2015 without a problem.
Non-surgical success
Between January 2010 and February 2013 I don’t have much in the way of details dealing with my shoulder injury other than attempting multiple periods of extended rest. This was largely unsuccessful for me, likely because it wasn’t matched with any significant therapeutic exercises.
During the later half of 2013 life found me taking significant time away from Ultimate. After being one of the final cuts from the Spinners, and without prospects for a good and serious club team I started rock climbing, a much more passive activity relative to Ultimate. I did go to a few tournaments with Jughandle and then Termite’s Entourage, but didn’t end up playing with either for the Series. At this time my wife moved to DC for work, and I was spending a lot of time finishing my Ph.D. thesis at Penn. It was apparent that the time away from Ultimate helped decrease inflammation; the stress of throwing (I’m a handler and puller for most teams I play for) wasn’t aggravating my injury anymore. I was living pain free, although still couldn’t bench press heavy.
In late 2013 and early 2014 I finished my Ph.D. and moved down to D.C., which is when my life started to equilibrate. Completely frustrated with my inability to properly workout my right shoulder, I started a regimented program to combat what I simply thought to be tendonitis or bursitis. I did a lot of light weight dumbbell lateral and forward raises, 12-15 pounds at most, high reps, low weight was key. I used the colored tension bands to do resistance training with my shoulder. A simple internet search will give you a host of ideas for shoulder resistance band training is easy to find. Here’s one link that could be helpful http://www.bodylastics.com/shoulders/, although I was largely self-sufficient, and independent in creating my own program based on prior training and experience.
My progress was apparent: By the summer of 2014 (this year) I had proceeded to heavier dumbbell lateral and front raises (25lbs) without any pain. There was fluctuation getting to the point. When I felt pain I’d drop the weight and increase the number of reps, but over 6 months of committed work, including stretching, good diet, and appropriate rest, I felt my shoulder was better than ever. For the first time in years I started adding weight to my bench press, getting up to 75#x5 dumbell press. I largely avoid barbell bench press because of the poor biomechanics that the activity forces on your shoulders (http://www.pponline.co.uk/encyc/bench-press-is-it-a-dangerous-workout-exercise-40883#). This links to a great read on how the biomechanics are problematic and how to modify your bench press to be safer for your shoulder. I won’t go into the details, here.
In August of 2014 I fortuitously found my way onto a mid-level strength Ultimate team (Sparkle Ponies) and instantly found my way in a big role as a starting D line handler. I felt great. I had put on about 10lbs of muscle since last I played, was rested, healthy, and excited to play. The only problem I noticed is that my once 80 yard pull was only 65-70 at most. I believe this was because of lingering shoulder weakness from not having played/practiced my pulls in nearly a year. It was a fun and successful, albeit short season capped by breaking seed and getting into quarterfinals at MA Mixed Regionals.
Background & detailing the acute injury
To start I think I’ll provide a bit of background. Today is Oct 29th, 2014. I first remember having shoulder pain following a layout at PUFF (same site where Mars is hosted, outside Pittsburgh) way back in 2005. Simply put, I landed more towards my side/armpit instead of on my chest. There were a few of these instances of the next 7-8 years but normally nothing that couldn’t be handled with a little bit of rest. Symptoms included pain mostly at the front of the shoulder where the biceps tendon, labrum, and rotator cuff sit, so really it could have been any of those pieces that was injured. Flick hucks were difficult for a while, but the real issue was bench press, more on this later.
The real moment of an acute injury that made this all get rolling is unclear. Maybe it was that bid 9 years ago, and I’ve progressively made it worse with each layout and 40 yard hammer? I’m usually pretty diligent about logging everything I can from each meal I eat, the supplements I’m taking, each rep and set of my workouts, and even my injuries. Based on my logs it seems likely that another major turning point (for the worse) was during a trip to Jamaica in January 2010. I was doing flat dumbbell bench press with 65s and slightly lost control with exhaustion on a later rep when my arms were about 80% extended from my chest. As I tried to catch the weight from falling laterally, I felt a distinct pain in my shoulder joint and immediately had to quit. At this point I was benching about my body weight (160-165 at the time), but never got back anywhere close to this for a long time. Still, in this case, rest and some lighter weight strengthening through lateral and front dumbell raises, cable rows, and tension band work, seemed to fix the issue. My shoulder became a more serious issue around the time of the second-year Philadelphia Spinners combines in February 2013. I’ve been the most detailed in logging my workouts since then, and it is clear that I have lost strength progressively in the past 20+ months. I was unable to bench any more than 125-135 pounds without serious pain, and usually with a higher number of reps would start to feel the pain at lighter weights. Additionally, I found that it was in the first 1/3 of the pushing motion that I felt the most pain.
So I set up this blog...
Hi. I'm Peter, but most people call me School. I am an amateur athlete, although given my history of injury, it feels far from an amateur pursuit. I've never considered myself very genetically gifted when it comes to athletics, but I am smart, determined, and stubborn. Because of my hard work I've found myself playing the sport I love at a fairly high level, but I haven't yet reached the highest plane I hope to achieve in this great sport.
In the following pages I am going to document my experiences and strategies to deal with what now appears to be a rather serious shoulder injury. I’ll accompany my entries, here, along with the occasional video log on my YouTube channel, as well. I’ll note where those corresponding video entries match up with my text.
I hope that this blog becomes both a release for me, as I experience what will certainly be a very trying experience for me, and also a tool for others in the future who will go through the same motions, some day.
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