3-week update of awesomeness

So many new things! As always, feel free to skip straight to “***big exciting bit” if you want to get straight to the best part of the post.

I have reached the 3-week milestone since surgery. Since having my stitches out I’ve enjoyed the return of a lot of mobility and freedom. A list of all the things I started doing in the past 7-10 days includes:

Showering - mostly without assistance!, though I still can’t use my surgically repaired right arm to wash my left)

Dressing - I have complete autonomy, most importantly being able to easily get socks and shoes on, though it takes some maneuvering of my un-slinged arm.

House work - I can hold light (<5lb) items in my right hand while in the sling. This allows for things like doing dishes to be possible again. It doesn’t seem like a lot, but I was starting to feel bad about all the things I couldn’t help Sarah with around the house.

Yard work - I can use the leaf blower (mostly one-handed), and can rake leaves, although I’m not actively pulling with the repaired shoulder, just lightly holding the rake with the bad arm and pulling with the good one.

Workouts - I mentioned this earlier, but the idea is that at two weeks post-surgery the site of repair reaches a point where it’s much more stable. This allows me to do things like standing squats or left-arm dumbbell press, which before I couldn’t, at least not without worrying I’d be somehow pulling on/activating my right shoulder. Jumping is also possible if I keep the arm in the sling and tight to my side!

My PT is going well, all range of motion progressing, although Friday was a bit of a nightmare. I had a different therapist since Lita wasn’t working that day, and this new lady was essentially apologizing at every manual bit of work she was doing. I was in pretty nasty pain for 24-36hrs after the session, and needed to use a full Percocet Friday night to sleep. Fortunately, the manual work being done on me is not strong enough to risk rerupture, but because I haven’t moved my shoulder in a normal way for so long, reintroducing these motions to my body can be really painful, mostly because of stiffness. Somehow me and this therapist just didn’t click. Word to the wise, *do not* lay and tolerate the pain. Some discomfort is expected, but your body is telling you it doesn’t like some movements for a reason. The ‘no pain, no gain’ attitude is not beneficial, in this case.

***Big exciting bit ---> Lita ‘graduated’ me to assisted active range of motion (AAROM), today. Essentially, lying flat on my back, I’m now allowed to work on external rotation, and overhead motion. I can do this by holding a stick/dowel/broom with both hands. The good arm holds on tight, and the right arm mostly hangs on for the ride, being assisted along the way for the two motions. Here are links to each motion I’m allowed to do, now:

1) External rotation <--video link

2) Overhead reach

24hr update: I’ve done my AAROM work 2x since therapy, yesterday. I already see a substantial improvement in ROM, including the ability to go chest-to-table on my table slides! This is mega-super-awesome progress!!

Also awesome, I am allowed to use the sling without the pillow, now, and can start weaning off the sling at home! Slightly less awesome, tried sleeping without the pillow under the sling, was very uncomfortable, then couldn’t get the pillow back into a good spot on the Velcro attachment and kept waking up with my right hand having fallen asleep. Sleeping well and through the night is still one of the bigger hurdles, but otherwise I’m thrilled about all my progress. Huzzah!

Excitement and surprise.

Incredible and unbelievable new developments in the past week. Jump right down to the fourth paragraph if you'd like to skip the more mundane, but still useful, details.

I'll first address a few smaller, but still important details. I'm currently through about 11.5 days following surgery. I have been mostly without any Percocet for the past 96 hours. Three of the last four nights I did use 1/2 a pill to help me sleep, as the discomfort is highest and most noticeable in the evenings, particularly when trying to sleep the whole night sitting upright. I've instead taken a few Tylenol during the day if needed, which don't make me drowsy, don't mess with my GI tract, and don't leave me dehydrated and tired. Also, when I came down from nine pills (day 1), to six (day 2), to four (day 3), I definitely felt what I would describe as withdrawal; even lying still in bed, I felt like I was on a boat, gently undulating on the waves.

Every day I also get a little more motion back with a little less pain. My pendulum exercises started at about Cheerios size and are now about 8-12 inches in diameter. In addition, getting in out of my sling, changing clothes, and taking a shower (without getting the stitches wet), have all become increasingly easier. The only crappy part is the sling continues to take a toll on my neck and shoulders, so I unclip every chance I am quietly sitting, and the therapist told be I could to scapular retractions as often as I wanted, which definitely helped the discomfort.

 Pendulum

Scapular retraction

On Friday (Day 10+), I had my third PT appointment. For the first time I started with a heating pad, which felt awesome. This is OK now that the main inflammation from the surgery is gone. Fun fact, day 10-11 is when the movement of type III collagen into the site of the repair is highest, and it will slowly deposit and start to turn to type I collagen as scarring sets in. Additionally, my therapist, Lita, did an incredible job activating my shoulder and doing some shoulder decompressions. I also did a new movement, which I can continue as often as I would like at home, called table slides. These can also be done with the body at a 45 or even 90 degree angle to the table, but I'm not going much past 45, now.

Table slides

The crazy stuff happened after PT. I went across the hall to get my stitches out to find that the middle of the three incisions on my arm was significantly larger than I anticipated. Instead of the standard arthoroscopic shoulder repair, Dr. Berdia had decided to do the mini-open version of the procedure. This did *not* involve detachment of the deltoid, as full-open requires, but does require the central incision is 4-5cm to allow more viewing and a larger portal to work in. The reason for the decision shocked me. As I mentioned in earlier posts, it was thought my supraspinatus had a 6mm full-thickness tear, and my infraspinatus had some fraying. As it turns out, once Dr. Berdia inserted the scope through the posterior incision he saw a TON more damage than he anticipated. The supraspinatus muscle runs under the clavicle and the tendon attaches to the humerus at a site about 14mm across. Apparently, my tendon only had 1-2mm of attachment remaining. The infraspinatus was not much better. At this level of damage, the muscles are barely functional at all.
Two things surprised my surgeon. First, he has never seen so much damage on a shoulder of such a young person. Usually, this level of insult is seen with older patients with chronic degenerative tendon issues. Second, he was impressed that I was able to play (and play pretty well) during the end of the last Ultimate season. Each time I threw a deep huck or pulled the disc, I essentially was risking shoulder dislocation, because of the weakness of the two tendons in questions. Part of their job is to anchor the shoulder in the socket. However, the last 18 months of weightlifting, with specific attention given to strengthening my deltoid and the rest of my shoulder complex (subscapularis and teres muscles) was apparently sufficient to compensate for the underlying injury. So what I thought was a simple stitch up of the one tendon became an intense bit of work that required putting four dissolvable anchors in to reattach both the supra- and infraspinatus. Wow.

Details on anchor placement. Tendon is then sutured to bone via anchors.

Fortunately, the severity of the injury has no bearing on the recovery time. Currently, according to the therapist, my range of motion (ROM) and overall strength are very good. At the end of next week we will start assisted active ROM, and then shortly after that I will leave the sling behind and go to full active ROM, for weeks 4-8. I'll start a heavier strengthening program around weeks 8-12, at which point I'll also be able to return to Ultimate, climbing, and weightlifting. In the meantime I'm getting in some KILLER leg workouts. One-legged skater squats are awesome!

So there you have it. Getting stronger every day!

Rehab day 1

Just 48 hours ago I was getting home from my shoulder surgery. I spent most of the past two days doing as little as possible and taking pain pills. Today, my routine changed, which welcomed, yet excruciating.

Physical therapy was less than 20 minutes, but it was very demanding. When I first met with the therapist we went over the details of my injury and surgery. She then watched as I removed my sling, making sure I was capable of safely performing this task on my own. Next she took two painful measurements as I was laying down. 1) Extension/lifting of the straight arm from the side, in the direction of the head. Full range of motion is 180 degrees leaving the arm outstretched above the head. I made it to 25 degrees. 2) The far more painful rotation, which was the lateral raise away from the side. Verdict? Intolerable pain at 7 degrees. Damn.

We did one exercise, the pendulum. I was so incredibly stiff while attempting my first unassisted motion post-surgery. It's hard to believe I was throwing 60 yard hucks in the wind just this past weekend. I'll continue to work on pendulum 3x a day until Monday, my next appointment. The good news is the therapist is saying my three month timeline is absolutely within reach if I work hard.

I came home to start this update after rehab, but only made it two sentences before I fell into a two-hour nap. My body is beat and I can feel it. On the plus side I am getting the rest I need, I don't go back to work until Monday, and Sarah helped me take my first shower, today!

Time to start getting that strength back! Do work!

Surgery prep, going under, & the first 24 hours

4-5 November 2014
It's done. The first day of my next season of Ultimate started, today. Here are some tips and a bit of info.

First off, as I noted in the last post, the doc originally thought I had a labrum tear, but the MRI showed it was in fact the supraspinatus tendon that had a 6mm hole in it. Well, when he went in to repair it he found another tear, this one in the infraspinatus tendon. (So, the radiologist was right!) Dr. Berdia also shaved out some bone spurs and worked on my bursa, but fortunately found no sign of arthritis! All in all, it was a very successful repair; the surgeon is thrilled with the immediate result, and believes I am off to a great start.

Let me take a step back, here. The day of the surgery, I woke up hungry because of the required fast. That sucked and made me irritable. Pro tip: Try to eat as much as you can, and eat/hydrate until the last minute the surgery prep directions allow.

Also...
- Make sure all services/doctors are in-network, if possible. 90% out-of-network coverage might sound good, but it will likely leave a hefty balance to pay on you own. Fortunately, my insurance has covered everything, so far.

-Getting nerve blocker injected directly into the nerve of your neck sounds awful, but they start dosing you up with goodies before that procedure. Nerve blockers give you that pins and needles feeling all day, but at least they keep the pain at zero for ~16 hours.

-I was considerably more lucid than the last go-around with general anesthesia (wisdom teeth), which of course was the great Nader-debacle of 2009. Coming out of sedation I threatened bodily harm to the surgeon, then started crying uncontrollably, and talked about voting for Ralph Nader 5 years earlier. No adverse effects this time around. I even woke up talking to the nurse about how to potentially cure one kind of lupus (Seriously! Ask me about it).

-I've had a pretty good appetite the whole first day, which is good. It's hard to feel ok taking Percocet with an empty stomach. About Percocet: the suggested dose is two pills every 4-6 hours, but I find taking 2x at a time is only good at night to help with falling asleep. I took two, this morning with breakfast and was too drowsy to do anything for three hours. The physicians assistant and I agreed that taking one pill every 2-3 hours instead should manage the pain without any risk of o.d. so long as I don't greatly exceed three grams, daily, of the included acetaminophen. This is the active ingredient in Tylenol and your liver can't handle much more than that amount in a 24 hour span. 

-On pain management (important!), stay ahead of the pain. The nerve blocker effects tapered off faster towards the end of last night after surgery than I anticipated. When I went to the polls to vote (yup, I sure did!) around 7pm, I started to feel sensation, mostly heat, return to the shoulder, so I took one pain pill. This was a mistake. By 10pm when I was trying to go to sleep I needed two more, but I was already behind the proverbial eight-ball; the next two hours were agony as my pain doubled and tripled before finally coming back down to a reasonable level. I could feel the spots of the scalpel incisions, it was as if they were being filled with molten lava or a hot roofing nail.

The good news is, now a full 24 hours after leaving the O.R., I am managing the pain fairly well, although it is still noticeable; shifting around, standing/sitting is fairly uncomfortable. I am still eating well, icing lots, and getting rest. It has taken me 3-4 sittings to finish this blog post, though, and I've only had enough energy for 2-3 short phone conversations - I feel pretty wiped out, but that is to be expected as my body was put through a fairly traumatic experience. DISCLAIMER, this is a graphic video! Although it is an example of a SLAP tear repair, the first three minutes of the video give a great example of how, even though arthroscopic shoulder repair is much better than open surgery, it is still a major insult to the local tissues!

I do have some gnarly internal images of my own shoulder (pre- and post-repair), which were captured by the surgeon while he was in there, but I only have the prints, and will need to scan them before I can post them, here. Until then, here is a less graphic video (internal camera, only) of what an actual rotator cuff tendon repair looks like, although this, too is not my actual procedure.

That's all, for now. I'll have another milestone, tomorrow as I take off the sling for my first session of PT.

Moving fast

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!

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.

https://www.youtube.com/channel/UCTYYZvzFtZUhimcPMfQAFvg

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.