Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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It is that time of year where baseball pre-season throwing is ramping up. I am starting to see throwers coming in to my clinic with shoulder and elbow issues. In many cases, injury can be avoided with proper stretching and strengthening as well as effective loading programs.
Pectoralis major/minor and latissimus muscle tightness along with poor scapular control often leads to postural dysfunction and shoulder problems. Improving shoulder mobility and scapular control can reduce injury risk and shoulder strain.
The video below from one of my Functional Fit columns will demonstrate an excellent exercise that can be programmed for every thrower to aid in optimizing shoulder mobility and promoting shoulder health.
I often use this exercise following soft tissue release techniques and in conjunction with thoracic spine extension mobilization on the roller. It is an excellent warm-up and activation exercise.
It has been a month since my last blog post. Things continue to improve. I would say I have recovered about 85% of my ROM to date. There is still some stiffness reaching behind my back, and I lack about 10-15 degrees of horizontal external rotation and elevation. Overall, my strength continues to improve, and I no longer have a shrug sign when I lift the arm up.
Pain
I am pain free the majority of the time. However, I have learned that overdoing it (trimming my bushes or pushing the weight with rows or simple horizontal presses in the gym) will remind me I am still not 100%. The shoulder will get sore if seated with pressure on the elbow for extended periods of time. However, the best part is sleeping pain free – the whole reason I had the surgery to begin with.
Work
I am having no issues working with my patients. I have realized that lifting my arm up against gravity with any resistance (e.g. stretching a client’s left hamstring) can be challenging if I have to hold the arm up for any extended period of time.
Exercise
I continue to do my pulley and ROM exercises daily. Meanwhile, a colleague stretches me 1-2x/week. I am doing scapular and rotator cuff exercises 3x/week, while I try to hit the gym at least 2x/week. I am sticking to exercises with my arms by my side for the most part. I have done some light pull downs and very gentle horizontal pressing. Admittedly, I am also being very cautious given the partial tearing on the right side.
What’s Next?
I have my final MD follow-up on 10/22. I am confident that my repair is healing as expected, yet also acutely aware I still have a long way to go before I am back to “normal.” I fully expect it to take a year before the shoulder no longer feels as if it is stiff, sore or weak at any given time.
As for the right shoulder, I plan to modify my lifting regimen and avoid risky exercises and activities. At some point in the next 2-3 years, I will explore having a subacromial decompression to remove the bone spur in the right shoulder and hopefully avoid a full repair.
Closing Thoughts
For those reading and hoping to avoid shoulder surgery, practice good posture, perform routine rotator cuff strengthening and be willing to adjust your exercises as you age to reduce strain on the cuff. This type of injury is more common in men, but overuse and repetitive motion can impact us all.
If you are experiencing ongoing pain at night and.or pain along the outer arm, I would advise you to seek further evaluation from a therapist or MD. If you have a bone spur like me, the situation is likely to worsen over time. If you treat it early, you may be able to avoid surgery altogether or just have the body decompression done, which leads to a faster and less painful recovery.
As I write this update, I have now been back to work for a month. The first 3 days back were challenging, as I had not done that much with my arm in quite some time. I was sore by 5 pm each day, but no significant pain. The soreness resolved by the next morning. I quickly realized how weak I was as I attempted to stretch a client’s hamstring lifting the right leg up with my left arm.
With that said, going back to work also facilitated me moving the arm more frequently and using it against gravity. This has allowed me to regain more functional mobility and strength the past month. I have been careful to avoid any heavy or overhead lifting. I have not encountered something I could not do yet in patient care, but I have had to be aware of my body mechanics and positioning to reduce strain on the left arm.
MD follow-up
I saw the doctor this past Friday. He was pleased with my progress and encouraged me to keep working on regaining the last portion of my ROM. I will go back for one final appointment in 6 weeks. Of note, I had previously asked him to image the right shoulder to see if I had a tear since I have been having some right shoulder pain that has worsened since the left shoulder surgery. The MRI revealed a partial tear (30-40% of mostly bursal-sided fibers), some degeneration in the anterior labrum, biceps inflammation and a sizable bone spur. In essence, the doctor says I need to have the bone spur taken out in the near future to avoid a full tear on my right side. Not great news, but I am relieved it was not fully torn.
Rehab and Exercise
I am continuing to get stretched 2x/week, while doing my pulley and ROM exercises daily at home. I am performing scapular and rotator cuff strengthening about 3x/week. I returned to the gym for the first time on Labor Day. This was a humbling day to be sure as I cannot even do 50% of my previous weight with pull downs, rows and other lifts. But, Rome was not built in a day, and I know it will likely take up to a year to get back to 100% again.
The last two weeks I have continued to see progress with my strength. My “shrug sign” lifting up my left arm is improving and now most noticeable when lifting my arm out to the side at 80 degrees and beyond. I have seen a steady increase in lifting capacity for my biceps and triceps but am still down more than 50% compared to my right side overall in strength.
New accomplishments
- Able to reach behind my head and wash my hair
- Able to drive and turn the steering wheel with just my left arm
- Begin wall push-ups and single arm rows
Remaining limitations
- Reaching up behind my back
- Unable to lay/sleep on left side
- Decreased elevation and external rotation
I have learned that the shoulder is still vulnerable if I do too much activity or push it too hard with the stretching. Generally, I stick to no more than 4/10 pain when doing passive stretching myself. In therapy, I have been just trying to block out the pain and endure the stretching even when it goes beyond that level. Last week, I had difficulty sleeping the same night following both of my PT sessions. I felt as if the PROM performed by the PT was more intense than it has been. While I was able to tolerate it during the session, the shoulder was increasingly sore and tight the same day after both sessions.
Well, I just saw my surgeon as I approach the 11 week post-op mark. I have made good progress since the steroid injection. Although I am still a little stiffer than we both would like, my ROM is progressing and my pain is gone aside from when I or my therapist really stretch it into end range.
Activities of daily living
I am now doing most things (bathing, dressing, grooming, etc.) using my left arm. It was a big deal when I could use my left arm in the drive through and ATM again lol. We tend to take the little things for granted until we cannot do them. I can turn the steering wheel with my left arm, although I will admit it is still a little challenging and fatiguing. Carrying light groceries is no sweat, and I have even started mowing my lawn with a self propelled lawn mower. Keep in mind my yard is flat and relatively small, so I would probably advise most patients to wait a bit longer on that.
Rehab recap
The past two weeks I have continued focusing on AROM and PROM while slowly progressing my strengthening exercises. My typical rehab session looks something like this:
- Heat x 10 min
- Active assistive cane ROM exercises x 20 each
- Pulley: 2 x 15
- Wall slides x 20
- UBE x 6 min
- PROM by PT for 20-30 min
- Serratus punches – 2 x 10
- Theraband rows and pulls – 2 x 10-15
- Theraband internal rotation – 2 xx 10
- Theraband external rotation walk outs – 2 x 10
- Side-lying external rotation (no weight) – 2 x 10
- Stabilization on the wall with a ball (up/down, side-to-side, circles) 2 x 10
- Prone extension (light weight) – 2 x 10
- Prone horizontal abduction (no weight) – 2 x 10
- Standing flexion and scaption (0-1#) 2 x 10 focusing on no shrug in my range of motion
- Ice x 10 min
The entire session takes about 90 minutes. Of course, I am navigating all the exercises on my own and relying on a colleague to do the PROM. With respect to the strengthening, my focus is on form, time under tension, avoiding excessive upper trap and compensatory motion, and ensuring I am not experiencing pain as I move the arm.
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