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.
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.
For all those following along with my journey, I have moved just past the 8 week post-op mark. I am pleased to report that I continue to see small steady improvements with my mobility during day-to-day activities as long as I am moving below shoulder height. I continue to have periodic and general low-level soreness at times (intermittent) but no marked pain unless really pushing my motion with stretching.
MD Follow-up
I recently saw the surgeon between weeks 6 and 7. He examined the shoulder and determined everything seemed to be progressing fine. I explained to him that I felt my passive range of motion (particularly flexion) felt limited by a pinching pain along the front of the shoulder in PT and at home. I also just felt that the shoulder was more stiff than I had hoped it would be at this point. He recommended giving me a steroid injection to help with inflammation and mobility. He assured me it would in no way compromise the repair.
See the article abstract below regarding early AROM after surgery:
https://pubmed.ncbi.nlm.nih.gov/31084488/
This was my first experience with cortisone. Patients have always told me 1 of 3 things:
- It’s magic and now all the pain is gone
- It hurts more initially but eventually after a few days they noticed some relief
- It did NOT help at all
The response for me was more in line with answer #2. The posterior shoulder was very sore within 2-3 hours after the injection, and the shoulder felt very heavy the rest of the day (motion actually seemed worse). In 24-36 hours, that pain and heaviness subsided, and I would say I could move the shoulder somewhat better in 72 hours. Since the injection, I have not had the pinching pain, and the motion seems to be getting better gradually. With that said, I still have some discomfort at times and a long way to go to recover all my motion as expected at this phase of the rehab process.
I passed a major milestone last Thursday as I hit the 6 week post-op mark. I have been transitioning out of the sling since week four (at home) while continuing to use the sling out in public. I officially quit using it last week. Things have been progressing, but two words really define the recovery so far: slow and incremental.
Being patient is no easy task when I am so used to working in the clinic, lifting weights and playing sports with my boys. Sleeping has still been a bit of a challenge as the shoulder aches after a few hours in one position, but I am now sleeping in my bed for 6-7 hours with only 2 disturbances per night. My mobility with dressing, shaving, showering and getting dressed is steadily improving. With respect to pain, it is absent at rest. However, it still strikes when I move the wrong way or happen to lift the arm against gravity due to weakness and stiffness.
Rehab
I have been going twice per week, but missed last week due to a summer vacation. I was diligent with my exercises 2x/day while away. Prior to leaving, my latest passive range of motion was equal to 117 degrees of flexion and 38 degrees of external rotation at 5 weeks post-op. As far as guidelines for the next 2-4 weeks, the goals are to restore ROM, resolve pain and begin light strengthening with rehab activities such as:
- Begin active assistive range of motion (AAROM) progressing to active range of motion (AROM)
- Continue with deltoid and rotator cuff isometric strengthening
- Begin light scapular strengthening – retraction (light rows), protraction (serratus anterior work), scapular depression and gentle ball stabilization work in a dependent position
- AAROM exercises with a dowel rod or cane (external rotation, extension, scaption, flexion, horizontal adduction/abduction)
- Joint mobilization, continued passive stretching to restore full range of motion and addition of shoulder pulley in this phase
- Light biceps and triceps strengthening (elbow at side)
- Scar massage
One important note: I have found the continued use of ice helpful in reducing daily soreness and discomfort following my home program. As such, I would highly recommend its daily use this late into the rehab.
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