Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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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.
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.
For those following my rehab journey, this entry will recap days 8-14 after surgery. At this point, I had been off pain meds for 4 days. However, I will admit I took one pain pill prior to my first PT session exactly one week out from surgery. For two decades I have listened to patients recount stories of their own or friends who report how painful therapy is after this surgery. Oddly enough, most of my patients over the years said it was not so bad. Perhaps, there is great variability in the intensity of the passive stretching among therapists.
Research Nuggets
The literature offers support and caution for early motion after rotator cuff repair. While ROM is generally better early on with early motion, there is some concern about higher re-tear rates. I am in the camp that gentle early passive range of motion (PROM) is okay given the proper regimen and patient compliance. Early active range of motion (AROM) or too vigorous PROM is likely to be more detrimental to the repair. Ultimately, these decisions are made based on the size of the tear, tear configuration, patient’s health and age, MD preference and whether or not this is a primary or revision repair.
The article abstract below is a great reference for activities and activation of the rotator cuff as measured by surface EMG to provide some insight for patients and clinicians regarding safe movement and exercise in the rehab process:
https://pubmed.ncbi.nlm.nih.gov/28704624/
In addition, here is another article that outlines post-op rehab (you can download the entire article for free)
https://pubmed.ncbi.nlm.nih.gov/29399735/
My First PT Visit
So, I would be lying if I said I was not nervous. I mean I was always the guy stretching the fresh post-op shoulders, and suddenly I am the one laying on the table a week out from surgery about to let someone move my stiff, sore shoulder. Fear of the unknown is probably the worst in that moment. My therapist is a colleague in my own clinic who actually reports to me. No pressure on him, right? LOL
He and I agreed to co-pilot my rehab and map everything out through constant dialogue and feedback. He has done a good job thus far. That first day the shoulder felt like a cement block to me. It seemed like super glue was preventing it from moving much. The focus was on gentle external rotation and flexion range of motion. Both hurt, but the flexion was by far the worst for me.
After doing pendulums and the PROM with him, my routine consisted of:
- Seated passive external rotation using a cane on my own – 2 sets of 15
- Scapular retraction (gentle squeezing of the shoulder blades together) – 2 sets of 15
- Seated table slides with a towel – 2 sets of 15
- Game Ready x 15 minutes with low compression
Dysfunctional movement is common with shoulder pain and impingement. One dysfunction you may encounter is a downwardly rotated scapula. If upward rotation is limited, a client will display excessive shoulder flexion above 90 degrees when the humerus is in maximal internal rotation. Typically, a person will have minimal flexion beyond 90 degrees if the scapula is moving properly.
Upward rotation of the scapula is the result of a force couple between the upper and lower trap along with the serratus anterior. If any of these muscles are weak, rotation can be limited and overpowered by the rhomboids and levator scapulae muscles (both downward rotators). This pattern of muscle dominance is common.
Additionally, tightness in the rhomboids, levator scapulae, pec minor or latissimus can also restrict normal mobility. It is probably safe to assume stretching of the chest and lats would be helpful, but it is critical to encourage the proper muscle firing patterns in the traps and serratus anterior as well.
Below is a video demonstrating wall slide shrugs. The shrug should be done at or above 90 degrees. You can perform reps at multiple angles or move to end range and perform a series there.
Application: The exercise is designed to encourage upward rotation in a more functional manner as opposed to traditional shrugs with the arms at the side. While I am not opposed to traditional shrugs with little or no weight for basic elevation, this position generally tends to activate the rhomboids and levator scapulae which is not desired given their natural dominance pattern.
The wall slide shrugs should not create any pain or discomfort. However, they may feel awkward particularly if the client has a faulty muscle activation pattern. As muscle tightness resolves and strength improves, clients should gain more mobility and optimal shoulder function.
I have been rehabbing rotator cuff injuries for the better part of 13 plus years now. I also have the privilege of teaching fitness boot camps, educating other fitness pros on training/rehab and training athletes. One of the most common issues I encounter in my work is rotator cuff pathology (tendinitis, tears, etc.).
I have sold well over 10,000 copies of my Ultimate Rotator Cuff Training Guide (e-book and print versions) since its release in 2004. While most of the training methodology is still sound today, I wanted to add some new content and tweak a few progressions. Like anything, with time you gain more experience and wisdom.
In addition, many people were asking me for the DVD version to better understand how to perform the exercises. So at last, I have released the DVD version. Some of the new additions include:
- Soft tissue mobility exercises
- Self assessment screening tools
- Integrating a towel roll with rotation exercises
In addition to the DVD itself, you get a companion CD-ROM with my Self Stretching Guide, personal interview on rotator cuff injuries, my 60 minute rotator cuff explained power point and audio seminar, the entire updated rotator cuff e-book, and 5 second video clips of each the particular exercises in the rehab plan.
I am selling this product for $49.95, but until next Wednesday (June 16) you can get it for only $29.95.
Click here to see a sample clip from the DVD
If you decide to grab a copy, simply use the code BFITCUFF (all caps) at checkout and be sure to hit apply to get credit for the coupon. You can order at www.brianschiff.com.
This DVD is ideal for people with acute or chronic nagging shoulder pain related to bursitis, scapular imbalances, rotator cuff tendinitis and rotator cuff tears. As always, I offer a 60 day money back guarantee on all my products. If you have any questions, simply post them on the blog.
Here’s to happier and healthier shoulders!
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