Today, I threw a Frisbee for the first time in six weeks!
It was only about a three-yard backhand, and it involved virtually no arm or shoulder movement at all, just a little flick of the wrist, but it felt so good to have a disc in my hand after so long. I did a killer leg workout and took one toss in between each set. It's not a lot, but I'm thrilled, and starting to feel closer to normal.
Sunday, December 14, 2014
Tuesday, December 9, 2014
Useful manuscript
Rehabilitation after arthroscopic rotator cuff repair: Current concepts review and evidence-based guidelines
The above links to the abstract for a great review article on the current ideas for treatment and recovery from the type of procedure I had. It should be a free article through PMC, but if there is trouble you can try this link, too, which is directly to the .pdf. The actual text includes pictures of many exercises, some of those I've discussed and some others. It also has an appendix table showing more-or-less when different phases of the rehab kick in. The nice thing is that for anyone reading this dealing with a slower recovery, due to age or complications, there is a timetable for a more conservative approach, as well.
The above links to the abstract for a great review article on the current ideas for treatment and recovery from the type of procedure I had. It should be a free article through PMC, but if there is trouble you can try this link, too, which is directly to the .pdf. The actual text includes pictures of many exercises, some of those I've discussed and some others. It also has an appendix table showing more-or-less when different phases of the rehab kick in. The nice thing is that for anyone reading this dealing with a slower recovery, due to age or complications, there is a timetable for a more conservative approach, as well.
Week 5 summary
Really short post, today, as I leave week 5 behind and start week 6 post-op.
Two modifications of old exercises, and a brand new one.
-Supine scapular retraction becomes prone scapular retraction.
-Front pulley raises adds lateral pulley raises. <-- video link!
-New exercise is internal rotation. Note that this image is NOT exactly what I'm doing, but it does illustrate internal rotation of the shoulder. The idea is to get into position as shown in the second image, on the right, and pull with the good arm, stretching the repaired shoulder into the midline of the body. I use a towel held in both hands to do this. Ideally the hand gets to/past the spine. I couldn't find a better picture of this one as the Google searches all came up with towel stretches in the vertical plane.
I've made nice progress in my other activities, though I still have tightness and pain when I'm doing them, especially soreness, afterwards. I am now able to lay on my back with my hands folded on my stomach without the need for a pillow under my right elbow.
Generally, it's still pretty hard, perhaps psychologically more so than physically, with moments of self-reflection feeling as if I'd made some mistake by putting myself through all this. I'm sleeping better but not great, I am unable to focus much at work because I'm constantly thinking about rehab, and I get frustrated with myself, often. However, these weekly reflections are helping as I can see the incredible progress that I have made. I am looking forward to shifting into full AROM and strengthening (phase III) soon.
Two modifications of old exercises, and a brand new one.
-Supine scapular retraction becomes prone scapular retraction.
-Front pulley raises adds lateral pulley raises. <-- video link!
-New exercise is internal rotation. Note that this image is NOT exactly what I'm doing, but it does illustrate internal rotation of the shoulder. The idea is to get into position as shown in the second image, on the right, and pull with the good arm, stretching the repaired shoulder into the midline of the body. I use a towel held in both hands to do this. Ideally the hand gets to/past the spine. I couldn't find a better picture of this one as the Google searches all came up with towel stretches in the vertical plane.
Prone scapular retraction
Internal rotation
I've made nice progress in my other activities, though I still have tightness and pain when I'm doing them, especially soreness, afterwards. I am now able to lay on my back with my hands folded on my stomach without the need for a pillow under my right elbow.
Generally, it's still pretty hard, perhaps psychologically more so than physically, with moments of self-reflection feeling as if I'd made some mistake by putting myself through all this. I'm sleeping better but not great, I am unable to focus much at work because I'm constantly thinking about rehab, and I get frustrated with myself, often. However, these weekly reflections are helping as I can see the incredible progress that I have made. I am looking forward to shifting into full AROM and strengthening (phase III) soon.
Tuesday, December 2, 2014
Week 4 update
I continue to remain ahead of the average recovery time. The therapist is being safely aggressive; listening to my body, but always pushing me more.
Now that I'm about a month post-surgery, here are some highlight from week 4:
-All week I was weaning myself off the sling, and I'm now not using it at all, during the day. I only wear it at night, but not to hold up my arm, rather more as a safety net to prevent something stupid from happening.
-Washing, changing, eating continue to get easier. I'm now able to feed myself with my right hand again (surgically repaired side).
-Three new exercises at the start of week 5: Overhead pulleys (it's easy to rig this up yourself w/a quick hardware store trip, or you can just buy a set), forearm wall slides (link is to a great website talking about the usefulness of this activity for anyone doing overhead sports like Ultimate, baseball, and tennis), and hands-behind head scapular retraction. I do this last one laying down, like I'm in the start of a sit up position. In addition to squeezing my shoulder blades together, I am also trying to force my elbows down/in towards my sides. I've got a lot of stiffness in my shoulder and my elbow on all of my exercises stays bowed out because of this stiffness. The new form of scapular retraction is meant to combat this.
I'm continuing my lower body & left arm workouts, but it's a little harder to keep up with now that all the shoulder exercises are mounting. It's important to mention how tiring this process is. I woke up from surgery having a repaired shoulder that *will be* better than it was. The problem is getting there. It is an incredible amount of work and very tiring going through all the therapy, even for a serious athlete, like myself. My therapist really put it in perspective for me: Not only am I recovering from the procedure, and the weeks of inactivity in the sling, but I'm also trying to now reprogram my shoulder to use normal mechanisms. For years, before the surgery my body had been compensating for the tears by altering the standard physiological motions, and now, with the new shoulder, I can hit the reset button.
Now that I'm about a month post-surgery, here are some highlight from week 4:
-All week I was weaning myself off the sling, and I'm now not using it at all, during the day. I only wear it at night, but not to hold up my arm, rather more as a safety net to prevent something stupid from happening.
-Washing, changing, eating continue to get easier. I'm now able to feed myself with my right hand again (surgically repaired side).
-Three new exercises at the start of week 5: Overhead pulleys (it's easy to rig this up yourself w/a quick hardware store trip, or you can just buy a set), forearm wall slides (link is to a great website talking about the usefulness of this activity for anyone doing overhead sports like Ultimate, baseball, and tennis), and hands-behind head scapular retraction. I do this last one laying down, like I'm in the start of a sit up position. In addition to squeezing my shoulder blades together, I am also trying to force my elbows down/in towards my sides. I've got a lot of stiffness in my shoulder and my elbow on all of my exercises stays bowed out because of this stiffness. The new form of scapular retraction is meant to combat this.
Overhead front pulleys
Forearm wall slides (usually done w/both arms parallel)
See video link!
See video link!
Supine scapular retraction
I'm continuing my lower body & left arm workouts, but it's a little harder to keep up with now that all the shoulder exercises are mounting. It's important to mention how tiring this process is. I woke up from surgery having a repaired shoulder that *will be* better than it was. The problem is getting there. It is an incredible amount of work and very tiring going through all the therapy, even for a serious athlete, like myself. My therapist really put it in perspective for me: Not only am I recovering from the procedure, and the weeks of inactivity in the sling, but I'm also trying to now reprogram my shoulder to use normal mechanisms. For years, before the surgery my body had been compensating for the tears by altering the standard physiological motions, and now, with the new shoulder, I can hit the reset button.
Tuesday, November 25, 2014
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:
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!
Saturday, November 15, 2014
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.
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.
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.
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!
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!
Thursday, November 6, 2014
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!
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!
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